The Brief Cognitive Assessment Tool (BCAT): A New Test Emphasizing Contextual Memory and Executive Functions

Drs. William Mansbach, Elizabeth MacDougall, & Andrew RosenzweigNovember 22, 2011

Dementia FactsOver 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 10-15 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 StudyStudy 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/+ education67% demented, 33% non-demented

BCAT Reliability & Validity StudyMethod

BCAT Reliability & Validity StudyMethod, continued

Characteristics Number PercentGender

Male 31 29.8

Female 73 70.2

Race

African-American 8 7.7

Caucasian 91 87.5

Missing 5 4.8

Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity StudyMethod, continued

Characteristics Number PercentMarital Status

Single, Never Married 5 4.8

Married 24 23.1

Divorced 7 6.7

Widowed 67 64.4

Missing 1 1.0

Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity StudyMethod, continued

Characteristics Number PercentEducation (years completed) 5-7 9 8.7

9-11 7 6.7

12 38 36.5

13-15 17 16.3

16 16 15.4

17-18 7 6.7

>18 9 8.7

Missing 1 1.0

Select Demographic Characteristics and Diagnoses of Participants

BCAT Reliability & Validity StudyMethod, continued

Characteristics Number PercentDiagnosis

No diagnosis 3 2.9

Mild Cognitive Impairment

31 29.8

Mild Dementia 36 34.6

Moderate Dementia 30 28.8

Severe Dementia 4 3.8

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, rs= .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, rs= -.08 (n = 66; median GDS score = 5.0).

BCAT Reliability & Validity StudyResults

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, ω2= .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 StudyResults, continued

MCI Mild Dementia Moderate Dementia

Participants n = 31 n = 36 n = 30

BCAT mean score 38.81 28.19 18.57

BCAT standard deviation 5.3 6.53 6.56

95% confidence interval for BCAT mean

36.86 – 40.75 25.99 – 30.40 16.12 – 21.02

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 StudyResults, 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 StudyResults, continued

Cut Scorea Sensitivityb Specificityb PPVb NPVb

35/36 .91 (.82-.97) .84 (.66-.94) .93 (.83-.97) .81 (.63-.92)

36/37 .96 (.87-.99) .81 (.62-.92) .92 (.82-.97) .92 (.82-.97)

37/38 .99 (.91-1.00) .77 (.58-.90) .91 (.81-.96) .96 (.78-1.00)

38/39 .99 (.91-1.00) .61 (.42-.78) .85 (.75-.92) .95 (.73-1.00)

39/40 .99 (.91-1.00) .52 (.33-.69) .82 (.72-.89) .94 (.69-1.00)

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

Item 1 2 3Story Recognition .76Delayed Story Recall .74

Immediate Story Recall .64Orientation .62Mental 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 Clusters1. Contextual Memory

• Immediate Story Recall• Delayed Story Recall • Story Recognition• Orientation

exam

ple “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 Clusters2. Executive Functions

• Verbal Trails (OTMT)• Mental Control (days of the week, backward)• Judgment• Arithmetic Reasoning• Digits Backward

exam

ple “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 Clusters2. Executive Functions

• Verbal Trails (OTMT)• Mental Control (days of the week, backward)• Judgment• Arithmetic Reasoning• Digits Backward

exam

ple

“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 Clusters3. Attentional Capacity

• Immediate Word List• Naming• Letter List

exam

ple

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 StudyDiscussion

The Brief Cognitive Assessment Tool (BCAT) Key Characteristics

Can be administered by professionals and paraprofessionals

21 items, 50-point scale

Can be administered in 10-15 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 – www.thebcat.com

“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 theprediction 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, LLCChief Operating Officer, MedOptions

wmansbach @ thebcat.com(443) 824-4208