The Brief Cognitive Assessment Tool (BCAT): A New Test Emphasizing Contextual Memory and Executive Functions Drs. William Mansbach, Elizabeth MacDougall, & Andrew Rosenzweig November 22, 2011

Dementia Facts Over 65 population projected to double from 36 million in 2003 to 72 million in 2030, and will increase from 12% to 20% of the total population Over 85 population also projected to double from 4.7 million in 2003 to 9.6 million in 2030 Alzheimer’s disease (AD) affects over 5 million Americans, with people 85 and older at the highest risk It is estimated that by 2050, 13 million Americans will have AD Current prevalence rates of dementia in SNF and ALF is at or above 50% Estimated cumulative costs associated with AD alone will exceed $20 trillion between 2010 and 2050

Mini-Mental State Examination (MMSE) Short Test of Mental Status (STMS) Montreal Cognitive Assessment (MoCA) St. Louis University Mental Status Examination (SLUMS) Brief Interview for Mental Status (BIMS) Why a New Cognitive Screening Tool?

Cognitive screening measures can be enhanced if they: can be administered by paraprofessionals and clinicians alike; can be completed in approximately minutes; can differentiate among MCI, mild dementia and moderate dementia; contain a strong, multi-level verbal memory component; have a broadly complex executive function component, and predict IADL performance.

Validate a new cognitive test Determine if the BCAT yields statistically robust Contextual Memory and Executive Functions clusters Determine if the BCAT is predictive of IADLs BCAT Reliability & Validity Study Study Objectives

111 Participants Largely from ALF IRB-approved study Participants referred to Memory Center for comprehensive neuropsychological evaluation Psychologists expert in dementia made CDR DX classifications without reference to BCAT scores Demographics: Ages 61-97, 88% Caucasian, 75% widowed, 75% 12/+ education 67% demented, 33% non-demented BCAT Reliability & Validity Study Method

BCAT Reliability & Validity Study Method, continued Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity Study Method, continued Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity Study Method, continued Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity Study Method, continued Select Demographic Characteristics and Diagnoses of Participants

Average inter-item correlation for the BCAT was.36 Internal consistency reliability, as estimated by Cronbach’s α based on standardized items, was.92. Test-retest reliability was r =.99. Convergent validity was demonstrated by the significant correlation of the BCAT with the MMSE, r s =.90, p<.001, and with the STMS, r =.84, p<.001. Discriminant validity was demonstrated by the absence of a relationship between the BCAT and the GDS, r s = -.08 (n = 66; median GDS score = 5.0). BCAT Reliability & Validity Study Results

Additional evidence of construct validity was demonstrated by the significant correlation of the BCAT with several measures of functioning and judgment, including the NAB Judgment scale BCAT mean scores were significantly different across the three diagnostic categories (i.e., MCI, mild dementia, moderate dementia), F(2, 94) = 82.03, p<.001, ω 2 =.63 Post-hoc (Bonferroni) analysis revealed significant BCAT mean score differences for MCI vs. mild dementia, p<.001, MCI vs. moderate dementia, p<.01, and for mild dementia vs. moderate dementia, p<.001 BCAT Reliability & Validity Study Results, continued

BCAT Scores by Diagnostic Category BCAT Reliability & Validity Study

The predictive validity of the BCAT was addressed with analyses of sensitivity, specificity, positive predictive value, and negative predictive value. The area under the ROC curve for the BCAT was.95, p<.001, 95% CI [.91, 1.00]. A BCAT cut-score of 38 yielded maximum sensitivity, with a PPV of.91, indicating a 91% likelihood of correctly diagnosing dementia. The NPV of.96 indicates a 96% probability of correctly determining that one does not have dementia. BCAT Reliability & Validity Study Results, continued

Regression analyses provided further evidence of the predictive validity of the BCAT. The BCAT total score was a significant predictor of basic and instrumental ADLs, as measured by the PSMS (ß= -.41, p<.001), and the Lawton IADL scale (ß=.63, p<.001) The 3 “clusters” were found to be predictive of diagnostic category and the IADL measure BCAT Reliability & Validity Study Results, continued

Predictive Utility of Several BCAT Cut Scores BCAT Reliability & Validity Study a BCAT cut-scores to classify participants into dementia /MCI diagnostic categories b 95% confidence interval in parentheses

BCAT Reliability & Validity Study | Principal Component Analysis: 3 Clusters Item1 23 Story Recognition.76 Delayed Story Recall.74 Immediate Story Recall.64 Orientation.62 Mental Control #1 Verbal Traits.81 Mental Control #2.63 Judgment.60 Digits Backward.55 Arithmetic Reasoning.55 Immediate Word-List Recall.75 Naming.67 Letter List.61 Language Repetition Summary of exploratory principal components analysis results for the BCAT (N = 104) Rotated Factor Loadings

BCAT: The 3 Clusters 1. Contextual Memory Immediate Story Recall Delayed Story Recall Story Recognition Orientation example “Carol borrowed $10 from her brother Jack last week. She couldn’t pay him back because she bought a delicious ice cream cone at the circus.”

BCAT: The 3 Clusters 2. Executive Functions Verbal Trails (OTMT) Mental Control (days of the week, backward) Judgment Arithmetic Reasoning Digits Backward example “Suppose you have a 1 PM appointment with your doctor. It takes 45 minutes to get there. What time is the latest you can leave to get there at 1 PM?”

BCAT: The 3 Clusters 2. Executive Functions Verbal Trails (OTMT) Mental Control (days of the week, backward) Judgment Arithmetic Reasoning Digits Backward example “You have $25 to spend at the grocery store. You buy milk for $3. You buy 2 apples for a $1. How much money do you have left?”

BCAT: The 3 Clusters 3. Attentional Capacity Immediate Word List Naming Letter List example Banana… Justice… Sara… Bridge…

Contextual Memory: utility of Story Recall, especially Story Recognition Immediate Word List recall: attention versus memory Executive Functions: utility of OTMT (Verbal Trails) Clinical considerations: “Cut” score Caution in generalizing Screening results require confirmation BCAT Reliability & Validity Study Discussion

The Brief Cognitive Assessment Tool (BCAT) Key Characteristics Can be administered by professionals and paraprofessionals 21 items, 50-point scale Can be administered in minutes Has a “cut” score separating dementia from Mild Cognitive Impairment (MCI) Has scores ranges for MCI, mild dementia, & moderate dementia Contains a multi-level verbal memory component Contains a broadly complex executive functions component Predicts Instrumental Activities of Daily Living (IADL) The BCAT website has an automated scoring program

Introducing the BCAT Website –

“Cut” score separating dementia from Mild Cognitive Impairment is 37/38 How to interpret the Contextual Memory Cluster How to interpret the Executive Functions Cluster How to interpret the Attentional Capacity Cluster Interpreting BCAT Scores

Mansbach, W. E., MacDougall, E. E., & Rosenzweig, A. S. (in press). The Brief Cognitive Assessment Tool (BCAT): A new test emphasizing contextual memory, executive functions, attentional capacity, and the prediction of instrumental activities of daily living. Journal of Clinical and Experimental Neuropsychology. Published BCAT Research

William E. Mansbach, Ph.D. Founder and CEO, Mansbach Health Tools, LLC Chief Operating Officer, MedOptions thebcat.com (443)