The Brief Cognitive Assessment Tool (BCAT):

1. 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

2. 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

3. Why a New Cognitive Screening Tool? 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)

4. 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.

5. BCAT Reliability & Validity Study Study Objectives 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

6. BCAT Reliability & Validity Study Method 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

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

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

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

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

11. BCAT Reliability & Validity Study Results 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).

12. BCAT Reliability & Validity Study Results, continued 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

13. BCAT Reliability & Validity Study BCAT Scores by Diagnostic Category

14. BCAT Reliability & Validity Study Results, continued 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.

15. 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

16. BCAT Reliability & Validity Study Predictive Utility of Several BCAT Cut Scores aBCAT cut-scores to classify participants into dementia /MCI diagnostic categories b95% confidence interval in parentheses

17. BCAT Reliability & Validity Study | Principal Component Analysis: 3 Clusters Summary of exploratory principal components analysis results for the BCAT (N = 104) Rotated Factor Loadings

18. BCAT: The 3 Clusters1. Contextual Memory • Immediate Story Recall • Delayed Story Recall • Story Recognition • Orientation “Carol borrowed $10 from her brother Jack last week. She couldn’t pay him back because she bought a delicious ice cream cone atthe circus.” example

19. BCAT: The 3 Clusters2. Executive Functions • Verbal Trails (OTMT) • Mental Control (days of the week, backward) • Judgment • Arithmetic Reasoning • Digits Backward “Suppose you have a 1 PM appointment with your doctor. It takes45 minutes to get there. What time is the latest you can leave toget there at 1 PM?” example

20. BCAT: The 3 Clusters2. Executive Functions • Verbal Trails (OTMT) • Mental Control (days of the week, backward) • Judgment • Arithmetic Reasoning • Digits Backward “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?” example

21. BCAT: The 3 Clusters3. AttentionalCapacity • Immediate Word List • Naming • Letter List Banana… Justice… Sara… Bridge… example

22. BCAT Reliability & Validity Study Discussion 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

23. 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

24. Introducing the BCAT Website – www.thebcat.com

25. Interpreting BCAT Scores “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

26. Published BCAT Research 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.

27. William E. Mansbach, Ph.D. Founder and CEO, Mansbach Health Tools, LLC Chief Operating Officer, MedOptions wmansbach @ thebcat.com (443) 824-4208