Results of Cultural Adaptation of Cognitive Stimulation Therapy (CST) for Elderly and Old Age People with Cognitive Impairment in Russia

Background. In Russia, the problem of maintaining cognitive well-being at a later age and helping elderly patients with dementia is an urgent task in the areas of healthcare and social protection of the population. The dynamics of the demographic situation in the country shows that by 2030, the older generation will make up almost a third of the population. At the same time, Russia is among the countries with the largest number of people with dementia. The aim of this study was the cultural adaptation of the Cognitive Stimulation Therapy (CST) program for elderly people with cognitive decline and dementia in a Russian-speaking sample with a pilot study of the use of CST in residential institutions on a group of elderly people with mild dementia. Methods. Cultural adaptation of the program was carried out within the framework of the Formative Method for Adapting Psychotherapy (FMAP) approach. The study used the official Russian translation of the manual for specialists conducting group classes “Making a Difference.” The sample consisted of several groups: (a) specialists (psychologists, medical workers, social workers) who participated in surveys with the aim of cultural adaptation of the management and procedure of the CST program, as well as receiving feedback after its implementation (n=25); (b) elderly people who participated in surveys for the purpose of cultural adaptation of stimulus material for the CST program (n=60, age 55–81 years (M=67.6, SD=6.2)); (c) elderly people with mild cognitive decline who participated in the pilot implementation of the CST program (n=5, age 68—83 years (M=75.8), MMSE and MoCA (n=5, M = 24.8 and 21.6, SD = 0.4 and 2.5, respectively). Six surveys were conducted: three in the form of face-to-face group discussions, two in the form of individual interviews, one survey was conducted online. Directed observation of the participants of the pilot study was also conducted (monitoring of progress, monitoring of support). The results are presented within the framework of the five stages of FMAP according to the “bottom-up” principle applied to the CST intervention. Results of surveys and observations received during the pilot study regarding feedback from program participants, staff of a residential facility for elderly patients with cognitive deficits, and group leaders were analyzed. Conclusions. The basic principles, structure of the intervention program and activities proposed in the CST manual are acceptable for use with Russian-speaking elderly people with mild dementia. The “Making a Difference” manual, translated into Russian and culturally adapted, is ready for use and further large-scale implementation of the intervention. The prospects for the study include assessment of effectiveness of CST on a Russian sample in various conditions (in the process of implementation), as well as development an online version of CST for the elderly population.

Introduction

The dynamics of the demographic situation in Russia show that by 2030, older people will make up almost a third of Russia’s population[1]. Thus, over the past five years, the number of people over 55 years old in Russia has increased by more than two million people, and people of the “third age” (60–74 years old) among them make up 55% (16% of the total population of the country). The demographic aging of the population[2] is associated, among other reasons, with an increase in the number of people with dementia and is a serious public health problem[3]. Already now, there are about 50 million people with dementia worldwide and their number increases by 10 million every year. In Russia, the number of patients with dementia is estimated at 1.85 million[4]. According to this indicator, Russia is among nine countries with the largest number of such patients (according to 2019 data)[5]. The number of patients with dementia may double by 2030 and triple by 2050, so preventing the development and progression of cognitive impairment is considered a priority health issue in Russia[6].

In this regard, the development of effective measures and interventions tools to maintain mental, physical, social, and economic well-being in old age is becoming increasingly relevant [8]. There are, however, differences between rehabilitation, training, and cognitive stimulation in interventions related to the prevention of cognitive impairment in old age [20]. Turning to the international practice, it has been shown that cognitive stimulation as a psychosocial intervention practiced with people with cognitive impairment in old age contributes to the improvement of cognitive functions and quality of life [43; 50; 28; 32] and does not depend on the use of pharmacological therapy [14].

Cognitive Stimulation Therapy (CST) is one of the most popular and used worldwide evidence-based [43] and cost-effective [29] programs for improving cognitive functions and quality of life in people with mild to moderate dementia [49]. CST was developed in the United Kingdom and for a number of years remains the only non-drug intervention recommended by Alzheimer's Disease International (ADI 2011, 2014), as well as by the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence (NICE-SCIE 2006, 2011, 2018) to improve cognitive functions and well-being in people with dementia.

Cognitive Stimulation Therapy (CST) is a 14-session program delivered twice a week in small groups of five or six people. Each session lasts about 45–60 minutes. It offers a variety of thematic activities (physical games, sounds, childhood, food, current affairs, faces and scenes, word associations, being creative, categorizing objects, orientation, using money, number games, word games, and team games) to stimulate thinking, concentration, and memory. The authors of the approach proposed a number of key principles for its implementation, such person-centered rather than focused on impairments, respect for individuality, striving to maximize the potential of each participant, and strengthening interpersonal relationships [45].

CST can be used in various settings and with various groups of people — in residential institutions for elderly people, war veterans [38], in day care centers, in hospitals and at home [30; 40]. A positive effect of CST has been shown for both people with dementia and personnel [31; 44]. Speaking about various settings for CST application, it is important to note another special category of people — those who live in involuntary isolation (in permanent residential facilities, hospices). Involuntary isolation raises acute problems of the emotional-personal, physical, cognitive state of a person and, as a consequence, the need for a specific system of assistance and support for this group of people. It has been shown that this category of people has a reduced desire for cognitive activity, difficulty adapting to living conditions, hypochondria, regression and/or aggression [5], low mood, and increased proneness to conflict [2].

CST provides elderly and old age individuals with cognitive decline and dementia, under any living conditions, with the opportunity to fully participate in social interactions where their opinions are valued [23]. A positive effect of CST on cognitive activity and productivity of cognitive processes in elderly patients with schizophrenia, permanently living in inpatient facilities, has been shown [19]. The program helps to improve their speech, memory, praxis, orientation [30; 17; 18; 26; 37; 41; 43], and also increases subjective well-being and quality of life [13; 18; 21].

Qualitative studies of CST are available in detail regarding (a) the appropriateness and feasibility of the intervention (b) its key features and (c) the effects of implementation. A systematic review of the results of such studies showed that the content of the CST manual was perceived by professionals as useful, important and sufficient to facilitate the program [14; 23]. However, effective implementation of CST requires additional resources, including time, physical effort and availability of facilitators. These requirements may result in CST being used less frequently than possible. In addition, several studies noted the importance of facilitators having sufficient experience and communication skills to deliver the program [23; 25].

The CST manual has been translated and adapted to many cultures and are currently used in 39 countries worldwide, in particular in Germany [47], Italy [18], India [39], China [48], Brazil [16], Malaysia [22], Portugal [15], and in African countries [33].

In Russia, the problem of maintaining cognitive well-being in old age and helping elderly patients with dementia is a pressing issue in the areas of healthcare and social security. This problem is being addressed in several areas: awareness and publicity, research, education, as well as practical assistance to the population [1]. An example of work in the awareness and publicity is MEMINI project (MEMINI Memory Academy), which offers the professionals’ recommendations on the prevention of age-related diseases and screening tools to the users. The research and educational areas include programs conducted at the Russian Gerontological Scientific and Clinical Center of N.I. Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. Among the most widespread socially-oriented programs of practical assistance, one can note the Moscow Longevity program, and among the intervention programs [6] — the cognitive training based on the network of the medical rehabilitation centers "Memory Clinic" (MС), represented in seven regions of Russia [7], or the work carried out by the Scientific Center for Mental Health [9]. The latter type includes the CST program as an intervention aimed at preventing cognitive decline, ameliorating the symptoms of dementia and improving the quality of life in old age. The use of the CST program on a Russian-speaking sample is just beginning [11]. A comparison of the basic principles of implementing the CST and MС programs [10] has shown that the CST program has key differences, including: a) the use of non-directed training, eliminating the limitations associated with self-stigmatization and allowing a wider range of people with neurocognitive deficit to participate in the program; b) implementation of the program by a wide range of specialists without special and lengthy training, provided that they have experience in the group work with the elderly, which allows for flexible application of the program based on the needs of specific institutions or places of residence [4].

The Objective of this study was the cultural adaptation of CST on a Russian-speaking sample, as well as a pilot study of the use of CST in a permanent residential facility on a group of elderly people with mild dementia. The study used the official translation of the manual for the professionals conducting group sessions on the Cognitive Stimulation Therapy program “Making a Difference” into Russian [45], created by a group of authors [3] and approved by the developers of the approach.

It should be noted that despite the relatively short period of existing attempts to use CST in the conditions specific for Russia, there are examples of the use of the approach characterized by non-compliance with the professional ethics and approaches to the adaptation procedure [13] and approbation of interventions recommended by the developers [46]. It is necessary to avoid this in further work on introducing the approach into the practice of helping individuals with cognitive decline in elderly and old age. Research groups from various countries in which CST has been adapted and used are listed on the official website of the developers of the approach: the International Center for Cognitive Stimulation Therapy of University College London[7].

Methods

Participants. The study consisted of several phases, according to which the participants were divided into several groups. The participants included (a) professionals (psychologists, health workers, social workers) who participated in the surveys for the cultural adaptation of the manual and procedure for conducting the CST program; (b) elderly people who participated in the surveys for the cultural adaptation of the stimulus material for conducting the CST program; (c) elderly people with mild dementia who participated in the pilot implementation of the CST program.

Surveys. During the study, six surveys were conducted: three surveys in the form of face-to-face group discussions, two in the form of individual surveys, and one was conducted online.

Survey 1. The respondents to the survey were elderly people who voluntarily participated in an open survey on thematic and social platforms on the Internet. The survey was conducted anonymously on a voluntary basis by filling out a Google form (n=60). The age of the participants was 55–81 years (67.6±6.2) [12].

Survey 2. The respondents to the survey were professionals experienced in working with elderly and old age individuals with mild cognitive decline (n=11), invited by the participants of the research project: two medical psychologists, one head of the social rehabilitation department, three social rehabilitation specialists, one physical rehabilitation specialist, two department nurses, two care-giving assistants. The survey was conducted on a voluntary basis, individually with each of the participants. All participants gave informed consent to participate in the survey.

Survey 3. The survey participants were professionals experienced in working with elderly and old age individuals with mild dementia (n=10), invited by Moscow State University of Psychology and Education (participants of the research project): three medical psychologists, a neurologist, a psychiatrist, and five academic psychologists. The survey was conducted on a voluntary basis in the form of a group discussion. All participants gave their consent to participate in the survey.

Survey 4. The survey participants were elderly and old age individuals with mild dementia, permanently residing in a social care residential facility, who took part in the pilot study (n=4, one of those who took part in the pilot study was absent due to illness at the time of the survey), aged from 68 to 83 years (average age — 75.8 years). The survey was conducted in the form of a group discussion. All participants gave their consent to participate in the survey.

Survey 5. The survey participants were specialists working with elderly and old age individuals with mild dementia (n=2) from among the employees of the social care residential facility in Moscow, on the basis of which the pilot study was carried out: a medical psychologist and a social rehabilitation specialist. The survey was conducted in the form of an individual interview. All participants gave their consent to participate in the survey.

Survey 6. The survey participants were experts in the field of age-related changes in mental activity and support for elderly patients with neurocognitive deficit (n=2). The experts were a psychologist and the head of a charitable foundation for supporting people with dementia and their families. The survey was conducted in the form of a group discussion of the report on the results of the study. The report was presented at a webinar, which was attended by 30 listeners. The total duration of the webinar was 60 minutes. All comments and suggestions were recorded on video.

Observation. The results of observing the behavior and mood of the participants in the pilot study group (n=5) were recorded by the group leaders (n=3, psychologists) in progress monitoring sheets, which were collectively filled in during the exchange of expert opinions on the results of each session throughout the program, as well as in support monitoring sheets, which were individually filled in by the group leaders accompanying the pilot study participants to the sessions.

Pilot Study. Individuals with mild dementia living in the social care residential facility in Moscow were recruited to participate in the CST pilot study. Participation in the study was voluntary. Participant selection criteria were the following: age 65 or older; MMSE scores of 18 to 22 points (average score 20.3); no significant visual or hearing impairments that cannot be corrected with glasses or hearing aids; no serious physical illnesses or other impairments that could affect participation. These inclusion criteria are recommended in CST studies and are the current standardized criteria [43].

Among 29 residents of the social care residential facility, five met all inclusion criteria, gave voluntary consent, and were selected to participate in the CST group. Exclusions were related to unwillingness to participate in group activities, severe sensory and motor deficits, and health deterioration at the start of the program. The participants were aged 68 to 83 years (mean age 75.8 years), male, MMSE=24.8±0.4, and MoCA=21.6±2.5 [12]. Two participants had impaired mobility (they used wheelchairs due to lower limb amputation). All participants were born and lived in Moscow. Two participants had a history of schizophrenia; at the time of the program, the disease was in remission in both participants. Participants had different lengths of stay in social institutions — from 1 year 2 months to 25 years 10 months (Table 1).

Table 1. Characteristics of the pilot study participants

Note: MMSE — total score, MoCA — total score, M — male gender, F20.xx according to ICD-10.

Procedure

The procedure for adapting CST in Russia was carried out within the framework of the Formative Method for Adapting Psychotherapy (FMAP) approach, based on interactions with the community and experts during the adaptation of intervention to different cultures and consisting of five phases according to the bottom-up model [13]. The FMAP approach was developed to increase the effectiveness and reliability of adapting psychotherapeutic programs for different ethnic groups. Currently, FMAP is successfully used to transfer psychotherapeutic practices to different cultural and linguistic environments. FMAP is based on collaboration with future recipients of assistance and includes five phases: (a) collaboration with the stakeholders of the psychotherapeutic program and studying their opinions about the intervention; (b) integration of the obtained information with theoretical, empirical and clinical data; (c) revision of the initial version of therapeutic intervention, considering certain cultural characteristics and the opinions of the stakeholders; (d) testing the culturally adapted intervention; (e) finalization of the culturally adapted intervention. FMAP is the main approach for cultural adaptation of CST in different countries.

Phase 1: Generating knowledge and collaborating with stakeholders

Considering both the guidelines for cultural adaptation of CST and the realities of the care system for people with cognitive decline and dementia in Russia, the professionals in the field of elderly care (psychologists, social and physical rehabilitation specialists, health workers and researchers) were invited as key stakeholders to discuss the use of CST, which allowed adding various professional and contextual opinions in understanding the possibilities of implementing CST (Survey 2). Respondents were asked to familiarize themselves with the materials of the CST manual "Changes for the Better". After familiarizing themselves with the materials of the CST program, specialists answered several questions related to their opinions on the advantages of CST compared to other approaches known to them. During the survey, the principles of organizing training sessions, criteria for forming groups, conditions for conducting sessions, as well as the specifics of the content of each session were also discussed. The discussion was held with each specialist individually and took 25 minutes. The survey results were recorded in paper form by two members of the research team.

Also at this stage, a survey “My Preferences” was conducted to identify the cultural experience, emotional significance of stimuli and preferences of older people in the Russian sample (Survey 1). The content of the survey was determined by the topics of the CST sessions and concerned architectural objects, household items, historical and cultural events, gaming, gastronomic and other preferences formed mainly in childhood and youth. The survey included 23 open questions and was conducted over the course of one month in Russian in an online format using a Google form. In addition to cultural preferences, respondents indicated sociological information about themselves: gender, age, place of residence (past and present). Information about the cognitive characteristics of the respondents was not collected. The results were analyzed by three members of the research team.

The experts’ suggestions and the results of the cultural preferences of elderly inhabitants were summarized for further synthesis of the program content.

Phase 2: Integrating generated information with theory and empirical and clinical knowledge

At this stage, the information collected during the first phase of the surveys was integrated into the context of the CST program. During the work, special attention was paid to the appropriate stimulus materials used in the program tasks. The proposed changes to the stimulus materials were included in the first version of the manual in Russian and allowed for a detailed description of 14 sessions using stimuli adapted to Russian culture. The sessions included the stimuli that could be easily recognized by the elderly population in Russia.

Phase 3: Review of the culturally adapted CST intervention by stakeholders and further revision

At this stage, the first version of the manual in Russian was presented to a new group of ten mental health professionals (Survey 3). The CST program and its structure (frequency, duration of sessions, participants, leaders and settings) were presented, as well as the key principles underlying its implementation and activities at each session. The participants were asked to rate the relevance of the program and the appropriateness of the proposed tasks and stimulus materials. The group discussion lasted 105 minutes, and two members of the research team recorded its results in paper form.

Phase 4: Testing the culturally adapted intervention

As part of phase 4, a pilot study was conducted at the social care residential facility in Moscow to assess the appropriateness of the CST program in Russia. Social care residential facilities in Russia are a part of the social security system. These are institutions for permanent residence of people who have partially or completely lost their ability to self-care due to mental disorders. Such institutions provide full support (cooking and serving food, cleaning, garment care, etc.), medical care (including monitoring medication intake), leisure activities, social and psychological rehabilitation.

Since the group participants lived on different floors and needed to be accompanied to the place of sessions, an additional opportunity arose to assess the group participants’ readiness for sessions, communicative activity and mood. When accompanying the participants, two members of the research team conducted observations and recorded the assessment results in the accompanying monitoring sheet.

Phase 5: Synthesizing stakeholder feedback from pilot and finalizing the culturally adapted intervention

The members of the research team discussed the results of the work after each session, recording their impressions in paper form in a standard protocol. Also, throughout the program, feedback from the personnel of the social care residential facility was recorded. All data were summarized and recorded in the report on the study. To discuss the cultural appropriateness and strategies for promoting CST in Russia, considering possible limitations of the program implementation in different settings, the members of the research group held an open webinar. At the webinar, a report on the phases and results of the study was presented, after which, during the discussion, the invited experts expressed suggestions and comments (Survey 6).

After the program, a group discussion of the results of the sessions was held with the study participants. The discussion lasted about 60 minutes. The results were recorded on video (Survey 4).

Two employees of the social care residential facility were asked to complete a questionnaire with questions about their impressions of the cultural appropriateness of CST in Russia, the advantages and limitations of the program that they noted (Survey 5).

Ethics. The surveys were conducted on a voluntary basis, having received the consent of the respondents. Informed consent was also obtained from the guardians of the pilot study participants.

Results

The results are presented within the five phases of the formative method of adaptation of psychotherapy (FMAP) from the bottom-up approach applied to the CST intervention. The survey materials and interview content have been analyzed. Illustrative quotes have been provided regarding the feedback from the program participants, personnel, and group leaders during the pilot study.

Phases 1–3. At phases 1 and 2, the CST program was found by health and social workers, psychologists and teachers to be culturally appropriate for the Russian population and applicable for implementation in various settings in which support and assistance is typically provided by the health and social care systems. No changes to the structure of the CST were proposed. The need to modify the culturally significant stimulus materials used in some activities was highlighted, namely, the adaptation of materials to present popular and familiar games, dishes, places, expressions, names and characters to Russians. The changes made to the content of each session resulting from surveys (Surveys 1, 2) were summarized and presented in Table 2. Following the implementation of phases 1 and 2, the Cognitive Stimulation Therapy manual for facilitators was translated and session scenarios were developed [3]. Based on the results of the activities at phase 3, positive feedback was received from mental health professionals regarding the relevance of the program and the appropriateness of the proposed tasks and stimulus materials.

Table 2. Cultural adaptation of stimulus materials and implementation procedures introduced into the CST for the Russian sample

Phase 4. In phase 4, the pilot study was conducted to assess the appropriateness and feasibility of the adapted CST program in the social care residential facility in Moscow. All sessions started on time (two hours before the lunchtime prescribed by the facility’s timetable), twice a week for 7 weeks. The group sessions were carried out by three psychologists. One participant in the pilot study dropped out due to hospitalization (after the 7th session). All sessions began with an introduction and ended with a farewell. During the session, a break for tea was always done before performing the main task. In a social setting, this part of the session could be used for some additional stimulation by offering the treats that are not usually included in the participants' menu. In addition to the food products themselves, their brand and packaging can be novel (pyramid-shaped tea bags, candies in wrappers with a closed edge, etc.), which also arouses interest and stimulates discussion in the group. The specifics of organizing and conducting the program within a social institution also include the need to accompany the participants from their actual place of residence (a room in a residential building) to the location of the sessions, which implies the necessity to take into account, on the one hand, the daily routine of the participants living in different departments of the institution, and on the other hand, the work schedule of the personnel involved in the program implementation process and the institution's services (arranging scheduled medical examinations, cultural events, etc.). Separately, we should highlight the need to consider the sanitary and epidemiological standards adopted in social institutions for permanent residence of elderly people. Here, difficulties may arise associated with the introduction of quarantine restrictions in different departments of the institution (asynchronous introduction of quarantine, complete long-term quarantine, etc.). For example, during the pilot study, the sessions were interrupted for up to three weeks due to the quarantine restrictions in the institution (the members of the research team could not visit the residential facility, and the participants of the therapeutic group could not leave their departments). Detailed information on the specifics of conducting 14 sessions is presented in Table 3.

Table 3. Sessions carried out during the pilot study

Phase 5. At the final phase of cultural adaptation, the feedback from the participants, specialists and group leaders about the sessions (strong points and obstacles to implementing the program, recommendations and suggestions for its possible improvement) was collected and summarized. The data from the Progress Monitoring Protocol was assessed.

Participants’ Feedback. According to the CST procedure, after each session, members of the research team asked the participants about their general impression of the session, what they liked and, on the contrary, what they did not like most. Among the most interesting impressions, the respondents often noted the discussion of news, activities in which they were more successful, or which evoked more emotions. The answers rarely contained negative feedback. Only one participant gave such answers (Participant 1). They were concerned the treats, the content of the news, how he looked in the photo, and by the middle of the program this participant began to suggest changing the choice of the group's song (“This is a song of the pioneers in taiga! We need another one.”) Since other participants did not support this initiative, the choice of the song remained the same.

The results of progress monitoring and the final survey of the group participants yielded positive feedback, noting the pleasant atmosphere during the sessions and the opportunity to be in a calm environment (“You can sit in silence.”) The participants unanimously noted a special interest in discussing the news during the sessions, recalling news that had evoked a lively response. The participants regularly inquired about the program’s prospects and expressed a desire to continue the meetings (“What will happen after the sessions are over?”, “Will you stay and work for us now?”, “When will you come again?”).

Feedback from the Residential Facility’s Personnel. The personnel of the social care residential facility noted that the program participants became more active in their everyday life and cultural events of the institution, willingly gave up current affairs (watching TV, communicating with neighbors, etc.) for attending the sessions, and returned from the meetings in a good mood. For example, one group member (Participant 3), after a session, noticing that a concert was taking place in the assembly hall, refused to return to the department and expressed a desire to attend the event. According to the personnel, he watched the artists’ performances attentively throughout the concert. Whereas previously this participant did not attend such events on his own initiative and, if he had to attend them, did not show interest in what was happening on stage. This can be considered an obvious sign of increased social activity and interest in the surrounding environment.

Also, according to the employees of the residential facility, another participant of the group (Participant 4) after session 8 “Being Creative” expressed a desire to exhibit a collage made by the group in the common area of the institution. This initiative was supported by the employees and administration of the residential facility, which gave the participants an opportunity to share the joy of creativity, to feel pride in their own achievements in the reference social group.

During the interviews, the staff reported that all participants enjoyed the program meetings, looked forward to the sessions, went to them with pleasure, and returned in high spirits, happily sharing their impressions and news that were discussed during the session. According to the psychologist we interviewed, Participant 4 noted that “There are always very interesting questions there”. “Everyone really enjoyed the tea break and pleasant conversations,” he also noted.

Professionals’ Feedback. The experts who took part in the discussion of the study results noted the high significance of expanding the existing practices of supporting patients with neurocognitive disorders in Russia by introducing the CST program. Among the most important effects of CST, an increase in the cognitive activity of the program participants, directed at themselves, was noted.

Group Leaders’ Comments. The group leaders noted that during the program implementation, the participants anticipated the next meeting with increasing excitement, readily responded to the invitation to attend a session, enthusiastically talked with their accompanying assistants, and inquired about the treats that would be offered. A gradual increase in the subjective significance of informal communication within the group was also noted. At the first meetings, most participants communicated only with the leaders, without communicating with each other. Also, not all group participants sang the song at the beginning and end of session 1. Gradually, the participants began to willingly join in singing the song, talk among themselves, and worry about whether everyone had enough treats for tea (“Have you tried these candies? They are very tasty, yes, take some more!”). They were interested in the health of one of the participants (Participant 5), who dropped out due to hospitalization, and readily responded to the group leaders’ offer to sign a postcard for him wishing him a quick recovery. During the news discussions, the members of the research team often used the Internet to clarify certain data at the request of the group participants, since the group participants did not have free access to the Internet (“Is not this artist still alive? What did he die of?”). In the third week of therapy, the group participants began to prepare questions in advance for searching the Internet and initiated a discussion of topics according to their personal interests (“I heard on TV that trolleybuses were canceled. Is it true?”). Such discussions began to take place during tea breaks. There were also cases indicating an increased attention of the group participants, directed at themselves. Thus, during session 6 “Faces and Scenes”, the group participants did not show much interest in their own images in the photographs, and by the end of the program, one of the participants (Participant 1) began to pay attention to the fact that photos and videos were being taken during the sessions. In the final session 14, he recognized himself in the photographs, realized that he was grey-haired, and got upset about it.

Sessions’ Evaluation by Pilot Study Participants. The participants’ attendance, interest, communication, enjoyment, and mood were rated at the end of each session by group leaders on a scale of 1–5 (1 = minimal involvement and 5 = maximal involvement). Table 4 presents data from the “Progress Monitoring Protocol” provided in the manual [3], demonstrating high levels of engagement with average scores of 4 for all parameters. Given the small number of participants, preliminary statistical analysis was not conducted. No changes were made to the sessions in phase 5.

Table 4. Descriptive statistics of the pilot study sessions

Note. The Progress Monitoring Protocol proposed in the CST Manual [3] was used. Attendance: maximum number of participants per session — 5 people. The Interest, Communication, Enjoyment and Mood indicators were assessed on a scale from 1 to 5 points.

Designations for assessments: x̅ — mean, SD — standard deviation, min — minimum, max — maximum.

The greatest spread of values is present for the parameter “Communications”. At the same time, this parameter has the highest upper limit (4 points). The most centered parameter is “Enjoyment” (3.45 points), which corresponds to the average indicators on the scale “Progress Monitoring” [12].

Discussion

The pilot study of practicing CST on a Russian sample complements the data on the adaptation of the program to different cultures using qualitative methodology [25; 15; 22]. As in other cases of cultural adaptation of CST, there was an obvious need to replace some of the original terms and stimuli with equivalents that are easily recognizable to Russian-speaking participants from Russia. For this purpose, a survey of elderly residents of Russia (n=60) was conducted about the most frequent, familiar and emotionally significant stimuli on the topics of the program sessions. According to the survey results, Russian-language linguistic and cultural features were used in 13 out of 14 CST sessions. Almost the same number of sessions was changed in the Portuguese adaptation (11 out of 14) [15]. As noted by A. Spector et al. [42], adaptation of tasks considering the use of local materials and equipment to ensure the sustainability of the program implementation is important for all adaptation locations. This applies to locally used and traditional foods and dishes, local maps, games, persons and characters, etc.

The content of the CST program did not cause any difficulties in implementing the pilot study. Despite the heterogeneous composition of the group in terms of pathogenetic parameters (diagnosis F20.xx according to ICD-10 in the remission phase, impaired mobility), the participants of the pilot study did not demonstrate disunity and were happy to join in the group work. Positive group dynamics were noted during the program implementation.

Not all participants in the pilot group had higher education, which did not prevent the sessions from discussing cultural news, modern technologies and new social practices. There was no need to adapt the tasks considering the illiteracy of the population, compared, for example, with African countries[8] [33]. It should be noted that experts attribute the high level of achieved education of the elderly population to the strong points of Russian active longevity (Active Longevity Index ALI, 2019[9]).

The greatest interest in the topic of discussion of current events for the Russian-speaking sample was in events on the current agenda in the world that had a general cultural or general scientific meaning, in contrast to the results of cultural adaptation, for example, in Tanzania, where preference was given to news and events in rural areas, since citizens' awareness of national news was limited [33].

The results of progress monitoring are on average lower than those obtained, for example, in a pilot study conducted in Portugal [15], which can be explained by the nature of patient support (in the case of the above-mentioned study, CST was carried out in a short-term post-stroke rehabilitation unit) and the clinical parameters of the sample.

In connection with the pilot implementation of the CST program in a permanent residential facility for elderly patients with cognitive impairments, a protocol for monitoring the accompanying group participants was proposed for the Russian sample, which allowed for additional assessment of the group participants' readiness for sessions, their communicative activity and mood. This monitoring showed the desire of the study participants to attend the sessions, a positive attitude and enthusiasm in anticipating the start of the sessions throughout the program.

The small sample size, heterogeneity of the group in terms of the parameters of the pathogenesis of cognitive decline, and gender homogeneity of the group composition (the group consisted only of men) do not allow us to draw conclusions at a high level of generalization. However, the data obtained in a small group, the results of discussions with specialists and with study participants allow us to optimistically assess the prospects for introducing CST into the broad practice of supporting Russian-speaking elderly people with mnestic-intellectual decline.

Limitations

The limitations of this study include, firstly, the sample characteristics. It was small, gender-homogeneous, and consisted of residents born and living in a metropolitan area. In addition, for all participants, the only native language is Russian, which, given the multinational composition of the country, may become a limitation for further scaling and generalizing conclusions.

Secondly, the study took place in a social residential institution in which all participants live permanently. In such institutions, sanitary and epidemiological regulations are in force, compliance with which may interfere with the recommended schedule of sessions. Due to these circumstances, the study had to take a break in the middle of the program due to the quarantine introduced in the institution, which could also affect the results.

Therefore, the results of the study on the possibility of using the cultural adaptation of the CST program in Russian should be interpreted with caution; generalization to other conditions is limited and will be assessed later.

Conclusions

The cultural adaptation and translation of the CST manual were conducted in accordance with the proposed recommendations for cultural adaptation (FMAP) by the research team of Moscow State University of Psychology and Education and were recognized as an acceptable intervention for mild dementia. The data obtained from observing the activities of the pilot study participants and their feedback, the feedback from the care-giving specialists, and the group leaders after the intervention allowed us to conclude that the basic principles, structure of the intervention program, and types of activities proposed in the CST manual are acceptable for use in working with Russian-speaking elderly people with mild cognitive decline and mild dementia. The translated into Russian and culturally adapted “Changes for the Better” manual is ready for use and further large-scale implementation of the program. The prospects for the study will be to identify the effectiveness of CST on a Russian sample in various settings (during implementation), as well as to develop an online version of CST for the elderly individuals [24].

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