The BCAT Approach: The Gold Standard in Rapid Assessment and Treatment of Cognitive Disorders in Older Adults Prepared by Dr. William Mansbach Founder & CEO, Mansbach Health Tools, LLC Home of the BCAT at www.thebcat.com Presented by Sarah Kneisler RMT/NHA at skneisler@new.rr.com Course Description Proficiency in the cognitive assessment of persons who have a subjective or objective memory or cognitive complaint is critically important to effective diagnosis, treatment, education, and support. This session will assist learners in understanding the three major cognitive stages: normal, mild cognitive impairment and dementia and understand why cognition should be assessed, understand the BCAT Gold Standard test systems and be able to apply test results to optimize care and promote the highest practicable functioning level. 2 1
Course Outline What is cognition and why should it be assessed? What is the BCAT Approach? The BCAT Interventions BCAT Science Empirical Evidence Why is the BCAT Approach Important? 3 Section I What is cognition and why should it be assessed? 4 2
Over 5 million people have Alzheimer s disease (AD), anticipated to be 13 16 million by 2050 Numbers are vastly greater if you include other dementias and people with Mild Cognitive Impairment (MCI) MCI dementia conversion rates (10 15% annually) A majority of MCI patients will develop dementia within 3 5 years. Background 5 The Assisted Living Resident of Today in Cognitive Terms In 2000, approximately 50% of ALF residents had a diagnosable cognitive impairment In 2010, 75 80% of ALF residents have a diagnosable cognitive impairment 750,000 individuals currently residing in ALF communities 6 3
Cognitive Functioning of ALF Residents: A Bird s Eye View 20% of residents are cognitively Normal 30% of residents have Mild Cognitive Impairment 50% of residents have Dementia (at varying stages) 7 What is Cognition? Cognition is the sixth vital sign Cognition is at the center of our experience Cognition consists of multiple domains Cognition is a fluid process Cognitive Task Manager (Attention, Contextual Memory, and Executive Functions) 8 4
Review of the Cognitive Continuum The Three Cognitive Stages: Bird s Eye View Normal: Inefficiencies but not pathology MCI: The four subtypes Amnestic (amci) Executive (emci) Multi domain (mmci) Undifferentiated (umci) or pre MCI MCI conversions to dementia Dementia: Mild, Moderate, & Severe 9 The Three Cognitive Stages (continued) Dementia: A matter of degree Progressive Cognitive, mood, behavior, function Causes (multiple) Background 10 5
Working Memory Temporary storage and management of information Lasts <30 seconds (more like 10 15 seconds) 4 5 pieces of new information 11 Working Memory Critical for improving memory Critical for buffering against future declines Consists of two phases Attention Cognitive Manipulation 12 6
Neuroplasticity Brain s ability to re organize itself Brain forms new neural connections Life long process that occurs naturally Brain rehabilitation concentrates the process 13 Cognitive Reserve Brain s ability to tolerate pathology and still function When the disease process has begun A method for buffering against cognitive decline 14 7
Section II What is the BCAT Approach? (Brief Cognitive Assessment Tool) 15 An Integrated Two Step Approach The BCAT Test System The BCAT The Kitchen Picture Test The BCIS The BCAT Interventions Online Brain Rehabilitation Modules The BCAT SF The BADS Working Memory Exercise Book MemPicsTM 16 8
17 The BCAT Test System Overview 1. The BCAT emphasizes three clusters: memory, executive functions, and attentional capacity. 2. The BADS can identify patients with symptoms of Depression and Anxiety. 3. The KPT measures practical judgment and safety. 4. The BCIS is appropriate for assessing severe cognitive impairment and creating behavior plans. 5. The BCAT SF is used when time is particularly limited and when patients can t tolerate a longer assessment. 18 9
The Brief Cognitive Assessment Tool (The BCAT) (Mansbach et al., 2012) Sensitive to full cognitive continuum (normal, MCI, dementia) with score ranges Particular emphasis on Mild Cognitive Impairment (MCI) MCI subtypes (amnestic, executive, multi domain and undifferentiated) Can be administered in approximately 15 minutes 19 The BCAT (cont.) Individual items measure orientation, verbal recall, visual recognition, visual recall, attention, abstraction, language, executive functions, and visuo spatial processing Measures the major domains ( clusters ) of contextual memory, executive functions, attentional capacity Cognitive Task Manager 20 10
The BCAT Short Form (BCAT SF) Abbreviated version of the full BCAT Can be administered in about three (3) minutes Pulls from the three full BCAT clusters Attention Contextual memory Executive functions 21 The BCAT Short Form (BCAT SF) Has six items 21 points Can be scored online Has a test report Cut scores differentiating normal cognitive functioning, Mild Cognitive Impairment and dementia 22 11
Use of The BCAT Short Form (BCAT SF) When time is at very short When the patient can t tolerate more than a few minutes A quick assessment once a full BCAT baseline has been established Often used in primary care offices Used by facility admissions staff 23 The Brief Cognitive Impairment Scale (BCIS) Assesses cognitive function with severe dementia 14 items 18 point scale Can track changes in severely demented residents and can provide information to manage behavior problems Use when the resident scores less than 50 on the BCAT 24 12
The Kitchen Picture Test (KPT) Visually presented test of practical judgment Pictures a kitchen scene with 3 potentially dangerous situations unfolding The individual is asked to describe the scene as fully as he/she can and then rank the order of importance of each situation in terms of its dangerousness, and then offer solutions that would resolve the three problems 25 The Kitchen Picture Test (KPT) (cont.) Successfully measures the construct of judgment Can be used to differentiate between those who have dementia and those who don t 26 13
The Brief Anxiety and Depression Scale (BADS) Process screening instrument that can rapidly assess anxiety and depression status Has separate depression and anxiety scores Cannot make a mood diagnosis on the basis of the BADS alone, however, this measure is highly accurate in identifying individuals with a high likelihood of having a clinical anxiety and/or depression diagnosis 27 The Brief Anxiety and Depression Scale (BADS) 8 questions Takes less than 5 minutes Can track mood over time Can be administered by a clinician, proxy* or as a self report measure Provides useful real time information Can be used with the cognitively intact, or the cognitively impaired 28 14
Section III The BCAT Interventions 29 The BCAT Interventions The BCAT Working Memory Exercise Book The BCAT Online Brain Rehabilitation Modules New and coming in the next portion of slides: MemPicsTMMeaningful Engagement Books 30 15
Key Tips and Guidelines Don t let the perfect be the enemy of the good Frustration minus 1 Successful exercise performance carry over is overrated Active versus passive therapist approach The three most important words: repetition, repetition, repetition D FEN = Difficulty + Frequency + Engagement + Novelty 31 About The BCAT Working Memory Exercise Book Based on science Exercises directed by a clinician Average session duration: 15 20 minutes Recommended 5 times per week Positive treatment effects often after 5 visits Exercises can be modified to fit skills of your patient Can be used in a restorative model 32 16
Structure of the BCAT Working Memory Exercise Book 15 exercise sections Basic versus Complex sub exercises Exercises introductions Background Procedure Tip BCAT insight 33 Application of BCAT Working Memory Exercise Below there are six objects. Sort them into two categories. Once this is done, attempt to memorize them. On the following page, list (or say) all objects by their identified category. You can try this multiple times. After each attempt, you may go back and review the objects from the previous page. Then try again. BASIC LEVEL: 34 17
Application of BCAT Working Memory Exercise COMPLEX LEVEL: 35 Application of BCAT Working Memory Exercise In the box below there are 12 words. Sort them into four categories. Once this is done, attempt to memorize them. On the following page, list (or say) all sixteen words by their category. You can try this three times. After each attempt, go back and review the words from the previous page. Then try again. 36 18
Application of BCAT Working Memory Exercise Below there are a series of images. Look at the image carefully. Your task is to try to flip the image vertically (upside down). Below each image, you will find three possible matches. Choose the correct one. 37 Application of the BCAT Brain Rehabilitation Modules Memory Match Works specific neuro circuits There are 3 difficulty levels, multiple themes Each round produces two types of scores o Clicks o Time 38 19
Memory Match: Level 2, Animal Kingdom Theme 39 Memory Match: Level 2, Animal Kingdom Theme 40 20
Application of 3 BCAT Brain Rehabilitation Modules Sort the Set Focuses on attention and cognitive set shifting Set shifting is an essential executive function Requires the patient to change cognitive sets, through switching between specific categories 41 Application of 3 BCAT Brain Rehabilitation Modules Sort the Set (continued) Works specific neuro circuits There are 3 difficulty levels Each round produces two types of scores (attempts, time) 42 21
Sort the Set: Level 1 43 Sort the Set: Level 2 44 22
Sort the Set: Level 2 (cont.) 45 Sort the Set: Level 3 46 23
Application of 3 BCAT Brain Rehabilitation Modules Color Illusion Focuses on selective attention Selective attention is closely associated with the executive functions Requires the patient to selectively attend to one task while not attending to a competing task Requires the patient to say words out loud The module is not automatically scored 47 Color Illusion: Level 1 48 24
Section IV BCAT Science Empirical Evidence 49 BCAT Science Empirical Evidence Can be administered by paraprofessionals or clinicians in ~15 minutes Sensitive to the full range of cognitive functioning (normal, MCI, dementia) Identify probable MCI sub types 50 25
BCAT Science Empirical Evidence (continued) BCAT vs. BIMs Emphasize attention, contextual memory, and executive functions (Cognitive Task Manager) Separate Contextual Memory Factor and Executive Functions Factor Scores Online Test Reports BCAT has been found to positively predict ADL and IADL performance 51 MMSE (Folstein, Folstein, & McHugh, 1975) The first major screening instrument Sensitive for moderate to severe dementia Less sensitive for MCI and mild dementia Education bias (overestimates for those with little education) Weak on memory and executive functions Floor effect Background 52 26
Section V Why is the BCAT Approach Important? 53 Why is the BCAT Approach Important? Consistent with a resident centered approach To optimize timely and effective treatment To target vulnerable off label antipsychotic use To reduce unnecessary hospital readmissions To reduce falls Improve discharge planning if appropriate Remember, COGNITION is a VITAL SIGN. 54 27
The BCAT Approach: The Gold Standard in Rapid Assessment and Treatment of Cognitive Disorders in Older Adults Prepared by Dr. William Mansbach Founder & CEO, Mansbach Health Tools, LLC Home of the BCAT at www.thebcat.com For additional information, or to become a licensed administrator, contact Sarah Kneisler at skneisler@new.rr.com 28