Brief Cognitive Assessment Tool
The Brief Cognitive Assessment Tool (BCAT) was designed and copywrited by Dr. William Mansbach to identify patients with and without dementia, and to be sensitive to different levels of cognitive impairment. The BCAT was designed as a multi-domain cognitive screening tool that assesses orientation, verbal recall, visual recognition, visual recall, attention, abstraction, language, executive functions, and visuo-spatial processing. The BCAT, as well as the three cognitive BCAT "factors" (contextual memory, executive functions, and attention), have been shown to predict both diagnosis and functional status or Instrumental Activities of Daily Living (IADL). The BCAT has been validated and published in the Journal of Clinical and Experimental Neuropsychology, 2012, Vol 34(2), 183-194. An abbreviated form of the Brief Cognitive Assessment Tool (BCAT-SF) has been published in the journal Aging and Mental Health, 2012, Vol 16(8), 1065-1071. The BCAT can be administered in 10–15 minutes.
Background
Over the past thirty years, cognitive functioning in older adults has become an important focus among clinicians and policy analysts. The increasing longevity of older adults, especially those in the "old-old" category, has been well documented. Epidemiological studies show that as people live longer, incidence and prevalence rates of dementia also increase. It is estimated that more than 5 million Americans over the age of 65 have Alzheimer's Disease (AD). This number is projected to exceed 13 million by 2050.
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. Furthermore, effective screening may aid in the development of intervention strategies that delay the insidiousness of the disease as well as nursing facility placement. Early detection may enhance the efficacy of pharmacologic and non-pharmacologic treatments.
A number of screening measures have been developed since the Mini-Mental State Examination (MMSE) was published in 1975. Examples include the Short Test of Mental Status (STMS), the Montreal Cognitive Assessment (MoCA), and the St. Louis University Mental Status Examination (SLUMS).
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. The BCAT was designed to overcome this and other measurement issues.
Whereas the BCAT can be administered in a short period of time (10–15 minutes), a Short Version (BCAT-SF) has also been developed and normed. It can be administered in less than five minutes and is ideal for primary care settings and frontline providers who have little time to spend screening patients. The BCAT-SF can be also be administered, scored, and interpreted on-line in "real time" (as can the full BCAT). The psychometric properties of the BCAT-SF are robust.
The BCAT Validation Study
Introduction
Important characteristics of the BCAT are that it:
- can be administered by both paraprofessionals and clinicians.
- can be completed in approximately 10–15 minutes.
- can differentiate among MCI, mild dementia, and moderate dementia.
- contains strong verbal recall components.
- has a complex executive function component.
- positively correlates with ADL and IADL performance.
Methods
111 participants referred for neuropsychological evaluation were recruited from assisted-living facilities. Participants completed a clinical interview, informant interview, record review, and a comprehensive battery of neuropsychological tests including the new BCAT. The total possible BCAT score is 50 points. The "cut" score is 37/38. That is, patients with scores of 37 and below are likely demented, whereas patients with scores of 38 and above, likely have MCI or, at the upper end of the scale, have normal cognitive functioning.
Design
Category |
Points Possible |
Description |
|---|---|---|
Orientation |
6 |
awareness of self, time, place, and situation |
Immediate Verbal Recall |
4 |
the ability to immediately recall a word list |
Visual Recognition/Naming |
3 |
the ability to accurate put names to objects |
Attention |
7 |
the ability to concentrate and focus |
Abstraction |
3 |
the ability to determine how objects are similar to one another |
Language |
3 |
the ability to understand and express speech |
Executive |
4 |
the "command and control" cognitive abilities |
Visuo-spatial |
4 |
the ability to understand visual processes and relationships |
Delayed Verbal Recall |
4 |
the ability to recall previously presented words after a time delay |
Immediate Story Recall |
2 |
the ability to immediately recall elements of a story |
Delayed Visual Memory |
3 |
the ability to recall previously presented pictures |
Delayed Story Recall |
2 |
the ability to recall elements of a previously presented story after a time delay |
Story Recognition |
5 |
the ability to recall previously presented story elements after cueing |
Normative Values
For the total BCAT score, we recommend using cut scores of 37/38. That is, scores of 37 and below indicate dementia; scores of 38 and above indicate MCI or no diagnosis. BCAT ranges are also reported below. They are intended as descriptive, but not diagnostic.
BCAT Crosswalk and Cognitive Functional Status
Cognitive Range |
BCAT Range |
Cognitive & Functional Issues |
|---|---|---|
Normal |
46-50 |
No functional deficit; independent living; May Be subjective memory complaints, but little to no objective evidence. |
Mild Cognitive Impairment |
34-46 |
Generally functionally normal, but early specific functional declines (IADL); subjective and objective memory deficits. Individuals at lower range more likely to have more significant cognitive deficits. Lower scores more suggestive of residential support needs. At the bottom range of MCI, consider medication management and consider support around community reintegration. |
Mild Dementia |
26-34 |
IADL deficits; typically requires residential support services; clear objective evidence of memory and other cognitive declines. Medication management and community reintegration support indicated for many people in this range. |
Mild to Severe Dementia |
0-25 |
Moderate (upper end of range) – Pervasive functional deficits (IADLs), but ADLs generally intact; marked deficits in memory and executive functions; behavioral and psychological symptoms are common; requires significant residential support. Severe (lower end of range) – Needs assistance in ADLs/IADLs; pervasive cognitive deficits; requires complex care. |
BCAT Crosswalk with MMSE & GDS
Cognitive Range |
BCAT Range |
MMSE |
GDS |
Cognitive & Functional Issues |
|---|---|---|---|---|
Normal |
46-50 |
26-30 |
1-2 |
No functional deficit; independent living; may be subjective memory complaints, but little to no objective evidence. |
Mild Cognitive Impairment |
34-46 |
24-27 |
3 |
Generally functionally normal, but early specific functional declines (IADL); subjective and objective memory deficits. Individuals at lower range more likely to have more significant cognitive deficits. Lower scores more suggestive of residential support needs. At the bottom range of MCI, consider medication management and consider support around community reintegration. |
Mild Dementia |
26-24 |
19-23 |
4 |
IADL deficits; typically requires residential support services; clear objective evidence of memory and other cognitive declines. Medication management and community reintegration support indicated for many people in this range. |
Moderate to Severe Dementia |
0-25 |
0-18 |
5-7 |
Moderate (upper end of range) – Pervasive functional deficits (IADLs), but ADLs generally intact; marked deficits in memory and executive functions; behavioral and psychological symptoms are common; requires significant residential support. Severe (lower end of range) – Needs assistance in ADLs/IADLs; pervasive cognitive deficits; requires complex care. |
Results
The psychometric quality of the BCAT was confirmed with strong evidence for reliability, construct validity, and predictive validity. The BCAT’s utility for detecting dementia was excellent, with a sensitivity of .99, a specificity of .79, and an area under the ROC curve of .95. Executive control items, contextual memory items, and attentional capacity items emerged as the best predictors of diagnostic category and of scores on a measure of IADLs.
Analyses supported the psychometric properties of the BCAT. The BCAT also was effective in integrating contextual memory, executive functions, and attentional capacity components as a predictive tool for diagnostic status and functional capacity.
The BCAT Test System
Those who use the BCAT and the BCAT-SF as a screening and diagnostic tool, can log onto the free website to utilize the scoring programs.
The complete BCAT Test System consists of four cognitive tools that healthcare professionals can use to assess memory and cognitive functioning. In addition to the Brief Cognitive Assessment Tool (BCAT), the System includes:
- The Brief Cognitive Assessment Tool Short Form (BCAT-SF): The BCAT-SF was designed as a shorter version of the full BCAT. The short form can be administered in less than five minutes. While it is not as robust, or comprehensive, as the full BCAT, the Short Version has strong reliability, construct validity, and predictive validity. When time is particularly limited (e.g., primary care settings), the six-item, 21-point short form is a dependable cognitive screening tool. It can be downloaded or used as an online tool.
- Kitchen Picture Test (KPT): 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 Cognitive Impairment Scale (BCIS): The BCIS was designed to assess the cognitive functioning of patients with severe dementia. The BCIS is a 14-item, 18-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.
See also
- Mini-Mental State Examination
- Montreal Cognitive Assessment