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
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