Brief Cognitive Assessment Tool

The Brief Cognitive Assessment Tool (BCAT®)

Type	Memory tools
Industry	Nursing Homes, Assisted Living, Home Health Care, Rehabilitation Therapy, Primary Care, and Mental Health
Founder	Dr. William Mansbach
Headquarters	Simpsonville, Maryland
Website	www.thebcat.com

The Brief Cognitive Assessment Tool (BCAT®)^[1] is a cognitive test designed and copywrited by Dr. William Mansbach to identify patients with and without dementia, and to be sensitive to different levels of cognitive impairment. It was designed as a multi-domain cognitive instrument that assesses orientation, verbal recall, visual recognition, visual recall, attention, abstraction, language, executive functions, and visuo-spatial processing.

The Brief Cognitive Assessment Tool is the primary test of the BCAT Test System, which consists of four other unique assessment instruments. Test scores can be used to guide the use of the BCAT Interventions designed to enhance cognition, promote independence, and provide meaningful engagement for those with memory loss. The integration of these assessments instruments, cognitive rehabilitation, and working memory exercises represent the The BCAT Approach.

Background

Cognitive functioning among older adults has become an important focus among clinicians and policy analysts. The increasing longevity of older adults, especially those in the "old-old"^[2] category, has been well documented.^[3] Epidemiological studies show that incidence and prevalence rates of dementia increase in line with continued increases in life expectancy.^[4] It is estimated that more than 5 million Americans over the age of 65 have Alzheimer's Disease (AD).^[5] This number is projected to nearly triple by 2050.^[6]

While no clear preventive or curative interventions for Alzheimer’s disease are available, early detection may improve quality of life for patients and their families.^[7][8] Furthermore, effective screening may aid in the development of intervention strategies that delay the insidiousness of the disease as well as nursing facility placement.^[9] Early detection may enhance the efficacy of pharmacologic and non-pharmacologic treatments.^[10]

A number of screening measures have been developed since the Mini-Mental State Examination (MMSE) was published in 1975.^[11] Examples include the Short Test of Mental Status (STMS),^[12] the Montreal Cognitive Assessment (MoCA),^[13] the St. Louis University Mental Status Examination (SLUMS),^[14] and Addenbrooke's cognitive examination (ACE).^[15]

While each of these instruments identifies individuals with probable dementia, they lack specific integration of three critical neuro-cognitive clusters (contextual memory, executive functions, and attentional capacity) as predictors of cognitive functioning and performance of everyday activities of independent living.^[16] The Brief Cognitive Assessment Tool was designed to overcome this and other measurement issues.

The BCAT Validation Study

The first page of the BCAT cognitive screening tool, complete with an online scoring and interpretive program.

In the original Brief Cognitive Assessment Tool validation study,^[17] a total of 104 older adults referred for neuropsychological evaluation were recruited from assisted-living facilities. Psychometric analyses from this sample confirmed strong evidence for reliability, construct validity, and predictive validity for the Brief Cognitive Assessment Tool. Its utility for identifying dementia versus mild cognitive impairment was excellent, with a sensitivity of .99, a specificity of .77, and an area under the receiver operating characteristic curve of .95. Executive control, contextual memory, and attentional capacity items were the best predictors of diagnostic category and of instrumental activities of daily living (IADL).

BCAT Test Design

Components	Description
Orientation	awareness of self, time, place, and situation
Immediate Verbal Recall	ability to immediately recall a word list
Visual Recognition/Naming	ability to accurate put names to objects
Attention	ability to concentrate and focus
Abstraction	ability to determine how objects are similar to one another
Language	ability to understand and express speech
Executive	"command and control" cognitive abilities
Visuo-spatial	ability to understand visual processes and relationships
Delayed Verbal Recall	ability to recall previously presented words after a time delay
Immediate Story Recall	ability to immediately recall elements of a story
Delayed Visual Memory	ability to recall previously presented pictures
Delayed Story Recall	ability to recall elements of a previously presented story after a time delay
Story Recognition	ability to recall previously presented story elements after cueing

The BCAT Approach

The BCAT Approach is a unique applied concept for assessing and working with people who have memory and other cognitive impairments. The BCAT Approach integrates three distinct systems: The BCAT Test System, the BCAT Brain Rehabilitation Program, the BCAT Working Memory Exercise Book and the MemPics® Book Series. All of the assessment instruments and interventions included in the BCAT Approach are interactive and available online.

The BCAT Test System

The comprehensive BCAT Test System consists of five cognitive tools that healthcare professionals can use to assess cognitive and mood functioning. All of the assessment instruments can be downloaded or used as an online tool complete with scoring programs.

• The Brief Cognitive Assessment Tool (BCAT):^[18] The BCAT is a multi-domain cognitive tool that contains 21 items. It produces a total score (50 possible points) and separate factor scores (contextual memory, executive functions) that can predict the full spectrum of cognitive functioning (normal cognition, Mild Cognitive Impairment, dementia) and functional status or Instrumental Activities of Daily Living (IADL).^[19] It is also used to predict discharge dispositions, facilitate advance healthcare directive determinations, aid in fall prevention programs, and help with non-pharmacological behavior management. The full BCAT can be administered in 10–15 minutes by professionals and technicians.
• The Brief Cognitive Assessment Tool Short Form (BCAT-SF):^[20] The BCAT-SF was designed as a shorter version of the full Brief Cognitive Assessment Tool. The six-item, 21-point BCAT-SF can be administered in less than five minutes. While it is not as robust or comprehensive as the full Brief Cognitive Assessment Tool, the BCAT-SF has strong reliability, construct validity, and predictive validity. It is particularly useful when time for assessment is limited (e.g., primary care settings). A Korean translation of the Brief Cognitive Assessment Tool – Short Form (BCAT-SF-K), which has been cross-validated in a Korean-American nursing home sample,^[21] is also available.
• Kitchen Picture Test (KPT):^[22] The KPT was designed as a visually presented test of practical judgment. The KPT is a unique illustration of a kitchen scene in which three potentially dangerous situations are unfolding. Patients are asked to describe the scene as fully as they can, to identify the three problem situations, to rank the order of importance of each situation in terms of dangerousness, and to offer solutions that would resolve the three problems.
• Brief Anxiety and Depression Scale (BADS):^[23] The BADS was designed as a screening instrument to rapidly assess current mood functioning. It consists of eight items and provides separate anxiety and depression factor scores. It can be administered in three to five minutes or less making it ideal to be used as a "process" instrument to track changes in mood over time. The BADS can be administered by a clinician, by proxy (a knowledgeable informant), or as a self-report measure. It can be used with individuals who have intact cognitive functioning or those with cognitive impairment.
• Brief Cognitive Impairment Scale (BCIS):^[24] The BCIS was designed to assess the cognitive functioning of patients with severe dementia. The BCIS is an 11-item, 14-point scale. It was developed to not only track cognitive changes in severely demented patients specifically, but to provide information to better manage those patients' behavior problems.

The BCAT Interventions

The BCAT Interventions consist of the BCAT Brain Rehabilitation, the MemPics® Book Series, and the BCAT Working Memory Exercise Book. They were designed to be used by clinicians in conjunction with the BCAT Test System. However, each of the BCAT Interventions can be used independently.

The BCAT Brain Rehabilitation

Brain rehabilitation is a loss and restoration process, based on cognitive exercises that promote brain cells (neurons) to improve functioning. It is based on the principles of neuroplasticity and cognitive reserve. Brain rehabilitation exercises can improve cognition and may protect against memory loss caused by brain diseases like Alzheimer’s disease.

The BCAT Brain Rehabilitation Program can be used as a cognitive rehabilitation program with the primary modules being online. They target attention, memory, and executive functions. It is intended for individuals with normal cognitive functioning, Mild Cognitive Impairment (MCI), or mild dementia. Brain Rehabilitation is not suggested for persons with moderate to severe dementia.

In an efficacy study, participants with mild cognitive deficits who received the BCAT Brain Rehabilitation had significantly higher post-treatment cognitive functioning relative to control group participants over the same period.^[25]

Interactive Modules	Cognitive Domain	Description
Memory Match (Interactive)	Attention and Memory	This module focuses on attention and visual memory requiring the brain to focus and create unique visual memories.
Sort the Set (Interactive)	Attention and Executive Functions	This module focuses on set-shifting, a frontal lobe executive function, requiring the brain to juggle multiple tasks and keep things in order.
Color Illusion (Interactive)	Attention and Executive Functions	Inspired by the Stroop effect, this module focuses on "selective attention" which requires one to selectively pay attention to one task while not paying attention to a competing task. These exercises can increase cognitive control, strengthen one’s ability to attend and focus, and improve executive functions.

Additional non-interactive brain fitness modules include Mazes, Word Searches, and Word Scrambles.

MemPics® Book Series

MemPics® is a book series activity program designed to meaningfully engage individuals with memory loss in fun and cognitively stimulating conversations. It is a verbally-based program that emphasizes conversation about familiar topics (people, places, objects, events) that are likely to be preserved in spite of cognitive impairments. MemPics has been found to promote significantly higher meaningful activity for long-term care residents with mild to moderate stage dementia compared to other recreation activities commonly available in long-term care facilities.^[26]

The BCAT Working Memory Exercise Book

The BCAT Working Memory Exercise Book consists of 15 exercises that target memory, attention, and executive functioning. It is designed for any clinical and residential setting in which cognitive functioning, independent living skills, and cognitive-communication are central issues. The Exercise Book is intended for professionals from numerous healthcare disciplines and patients who experience mild to moderate cognitive impairment and dementia caused by strokes; acquired brain injuries; or neuro-degenerative illnesses, such as Alzheimer’s disease.

See also

• Mini-Mental State Examination
• Montreal Cognitive Assessment
• Addenbrooke's cognitive examination

References

A full listing of peer reviewed publications can be found on the BCAT Research Center website.

1. Mansbach, W. E.; MacDougall, E.E.; Rosenzweig, A.S. (2012). "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. 34 (2): 183–194. doi:10.1080/13803395.2011.630649. PMID 22149477.
2. "Demographics of Aging". Transgenerational.org. Retrieved 2016-04-04.
3. https://www.nia.nih.gov/research/publication/global-health-and-aging/living-longer
4. Jagger, C., Matthews, R., Lindesay, J., Robinson, T., Croft, P., & Brayne, C. (2009). The effect of dementia trends and treatments on longevity and disability: a simulation model based on the MRC Cognitive Function and Ageing Study (MRC CFAS). Age Ageing, 38(3), 319-325. doi: 10.1093/ageing/afp016
5. Alzheimer’s Association. 2016 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia 2016;12(4).
6. Alzheimer’s Association. 2016 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia 2016;12(4).
7. Watson, Lea C.; Lewis, Carmen L.; Moore, Charity G.; Jeste, Dilip V. (2011). "Perceptions of depression among dementia caregivers: findings from the CATIE-AD trial". International Journal of Geriatric Psychiatry. 26 (4): 397–402. doi:10.1002/gps.2539.
8. Vitaliano, Peter P.; Zhang, Jianping; Scanlan, James M. (1 January 2003). "Is Caregiving Hazardous to One's Physical Health? A Meta-Analysis". Psychological Bulletin. 129 (6): 946–972. doi:10.1037/0033-2909.129.6.946.
9. Burdick, D. J.; Rosenblatt, A.; Samus, Q. M.; Steele, C.; Baker, A.; Harper, M.; Mayer, L.; Brandt, J.; Rabins, P.; Lyketsos, C. G. (1 February 2005). "Predictors of Functional Impairment in Residents of Assisted-Living Facilities: The Maryland Assisted Living Study". The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 60 (2): 258–264. doi:10.1093/gerona/60.2.258.
10. Mansbach, W.E. (October 2011). "The New Brief Cognitive Assessment Tool (BCAT): The Role of Cognitive Assessment in Improving Health Outcomes." (PDF). Paper presented at the October meeting of the Health Facilities Association of Maryland.
11. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198
12. Kokmen, E.; Smith, G. E.; Petersen, R. C.; Tangalos, E.; Ivnik, R. J. (1991). "The Short Test of Mental Status: Correlations with standardized psychometric testing". Archives of Neurology. 48 (7): 725–728. doi:10.1001/archneur.1991.00530190071018.
13. Nasreddine, Z. S.; Phillips, N. A.; Bedirian, V.; Charbonneau, S.; Whitehead, V.; Collin, I. (2005). "The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment". Journal of the American Geriatrics Society. 53 (4): 695–699. doi:10.1111/j.1532-5415.2005.53221.x. PMID 15817019.
14. Tang-Wai, D. F.; Knopman, D. S.; Geda, Y. E.; Edland, S. D.; Smith, G. E.; Invik, R. J. (2003). "Comparison of the Short Test of Mental Status and the Mini-Mental State Examination in mild cognitive impairment". Archives of Neurology. 60 (12): 1777–1781. doi:10.1001/archneur.60.12.1777.
15. A.J. Larner (10 January 2012). Dementia in Clinical Practice: A Neurological Perspective: Studies in the Dementia Clinic. Springer. p. 31. ISBN 978-1-4471-2361-3.
16. Naugle, R. I.; Kawczak, K. (1989). "Limitations of the Mini-Mental State Examination". Cleveland Clinic Journal of Medicine. 56 (3): 277–281. doi:10.3949/ccjm.56.3.277.
17. Mansbach, W. E.; MacDougall, E.E.; Rosenzweig, A.S. (2012). "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. 34 (2): 183–194. doi:10.1080/13803395.2011.630649. PMID 22149477.
18. Mansbach, W. E.; MacDougall, E.E.; Rosenzweig, A.S. (2012). "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. 34 (2): 183–194. doi:10.1080/13803395.2011.630649. PMID 22149477.
19. Mansbach, W.E.; MacDougall, E. E (November 2011). "The Oral Trail Making Test as a Predictor of Dementia & IADLs" (PDF). presented at the Gerontological Society of America annual meeting.
20. Mansbach, W.E.; MacDougall, E.E. (2012). "Development and validation of the short form of the Brief Cognitive Assessment Tool (BCAT-SF)". Aging & Mental Health. 16 (8): 1065–1071. doi:10.1080/13607863.2012.702729.
21. Mansbach, W. E., Mace, R. A., & Clark, K. M (2015). Preliminary investigation of the psychometric properties of the Korean version of the Brief Cognitive Assessment Tool – Short Form (BCAT-SF) for Korean-American nursing home residents. Research in Gerontological Nursing, 8(1), 50-56. doi: 10.3928/19404921-20141110-02
22. Mansbach, W. E., MacDougall, E. E., Clark, K. M., & Mace, R. A. (2014). Preliminary Investigation of the Kitchen Picture Test (KPT): A New Screening Test of Practical Judgment for Older Adults. Aging, Neuropsychology, and Cognition, 21(6), 674-692. doi: 10.1080/13825585.2013.865698
23. Mansbach, W. E.; Mace, R. A.; Clark, K. M (2015). "The Brief Anxiety and Depression Scale (BADS): a new instrument for detecting anxiety and depression in long-term care residents.". International Psychogeriatrics. 27 (4): 673–681. doi:10.1017/S1041610214002397.
24. Mansbach, W. E., Mace, R. A., & Clark, K. M. (2013, November). The BCIS: A New Test for Assessing Severe Cognitive Deficits. Poster presented at the Gerontological Society of America annual meeting, New Orleans, LA available online
25. Mansbach, W. E., Mace, R. A., & Clark, K. M. (in press). The Efficacy of a Computer-Assisted Rehabilitation Program for Patients with Mild Cognitive Deficits: A Pilot Study. Experimental Aging Research. Advance online publication. doi: 10.1080/13825585.2016.1143443
26. Mansbach, W. E., Mace, R. A., Clark, K. M., & Firth, I. M. (in press). Meaningful activity for long-term care residents with dementia: A comparison of activities and raters. The Gerontologist. Advance online publication. doi: 10.1093/geront/gnv694