MCI Today, Dementia Tomorrow: Improving Clinical Strategies Presented by Dr. William Mansbach CEO & Founder, Mansbach Health Tools, LLC www.thebcat.com

Highlights on Prevalence Over 5 million Americans 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) 15-20% of people 70 and older have MCI

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

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) MCI conversions to dementia Dementia: Mild, Moderate, & Severe

Normal Cognition Anticipate cognitive decline Peak in the 30’s Plateau in the 50-60’s Slow decline in the late 70’s

Normal Cognition Working Memory is reduced Cognitive processing speed declines Reduced cognitive flexibility

A Consensus Set of MCI Criteria A subjective or objective concern regarding a change in cognition Impairment in one or more cognitive domains (decline from previous performance) General preservation of functional abilities (can have mild problems) Not demented Cognitive deficits not primarily caused by delirium or Axis I (psychiatric) disorder

Problems with the “Functional” Criterion Substantial evidence that “higher order” functional abilities can be compromised in cognitively impaired patients who do not meet criteria for dementia. Many clinicians don’t actually assess functional skills.

Additional Insights “Mild Cognitive Impairment” – misleading term Transitional Cognitive Impairment – more accurate An “in-between” state of impairment 10-15% conversion rate to dementia Reversion rates to normal

MCI Subtypes based on BCAT Research Amnestic (aMCI) Executive (eMCI) Multi-domain (mMCI) Undifferentiated (uMCI)

What is Amnestic MCI? The primary issue is memory Memory prospectvely, not retrospectively Approximately 70% of MCI cases Strong conversion to Alzheimer’s disease (AD)

What is Executive MCI? Impairment in one or more executive skills Set-shifting, reasoning, judgment, problem solving Divided attention is often a problem Look for deficits in performing IADLs Strong conversion to AD and other dementias

What is Multi-domain MCI? Impairment in multiple domains Typically in attention, memory, and executive functions May or may not be more severe than single domain MCI Strong conversion rate to AD

What is Undifferentiated MCI? Deficits are not clearly expressed in one or more cognitive domains Higher percentage of reversion to normal Look for medical contributors Conversion to AD is unclear

A Few Words about Dementia… Severe and disabling Strong impact on function Progressive Cognitive, mood, and behavior Multiple causes

“The State of the State”: Why Non-medication Memory Interventions Matter Very limited effectiveness of medications (nootropics) Positive effects of neuroplasticity Positive effects of cognitive reserve Premium matching interventions with patient/resident cognitive capabilities

The Importance of Starting with Cognitive Assessment Subjective diagnoses are inaccurate Using BCAT cognitive test scores to plan cognitive treatments

The BCAT Approach The BCAT Approach is a unique applied concept for assessing and working with people who have memory and other cognitive impairments. It is designed for any clinical and residential setting in which cognitive functioning and cognitive impairment is a central issue. The BCAT Approach integrates the BCAT Test System, BCAT Brain Rehabilitation Modules, the BCAT Working Memory Exercise Book, and the MemPicsTM series.

The Four Components of the BCAT Approach The Test System rapidly, yet comprehensively, assesses current cognitive functioning and depression/anxiety. Online Brain Rehabilitation modules are guided by Test System scores.

The Four Components of the BCAT Approach (continued) The BCAT Working Memory Exercises approaches are developed based on patient cognitive capabilities and can be used for acute and post-acute phases of rehab. The MemPics series are designed to produce meaningful engagement in persons with cognitive impairment.

The BCAT Test System Descriptions 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. Cognitive staging, Memory Factor Score, and Executive Functions Score provide essential clinical information. The BCAT-SF was designed as a shorter version of the full BCAT and can be administered in three minutes or less.

The BCAT Test System Descriptions (continued) The BADS was designed as a "process" screening instrument to very rapidly assess depression and anxiety status. It can be administered in three minutes or less. The Kitchen Picture Test of Judgment (KPT) was designed as a visually presented test of practical judgment. It can be administered in less than five minutes. The BCIS was developed not only to track cognitive changes in severely demented patients specifically, but to provide information to better manage behavior problems. It can be administered in less than three minutes.

The BCAT Test System – The Five Tests The Test System is a comprehensive approach for rapid assessment of memory, executive functions, and attentional capacity. The “Main” BCAT (21 items) is the featured test. The other four tests make unique contributions to assessment We recommend administering the BCAT and BADS first. The System is an excellent method for tracking cognitive and mood changes over time. All tests have interactive online scoring programs with test reports.

A Close-up of the Main BCAT 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)

A Close-up of the Main BCAT Memory and Executive Functions Factors Full, Memory Factor, Executive Functions Factor scores Helps predict: ADL, IADL, “falls,” residential placement, “person-centered” ability to participate in care decisions Interactive website scoring program with test report

The BCAT Short Form (BCAT – SF): What is it? 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

The BCAT Short Form (BCAT – SF): What is it? Has six items 21 points Can be scored online Has a test report “Cut” score differentiating dementia, MCI (without sub-types), and normal

Psychometrics for the BCAT and BCAT-SF Note: These tests have been validated and normed in multiple clinical settings. Each patient population is associated with specific psychometric values. BCAT BCAT-SF Sensitivity .99 .90 Specificity .77 .81 PPV .91 .95 NPV .96 .74

Philosophically… Person-centered care Life quality (from the perspective of the person) Demented older adults are still ADULTS Purposeful engagement Impact on cognition Impact on mood

Meaningful Engagement as a Care Intervention

Let’s Begin with BPSD Three “clusters” Behavioral dyscontrol Mood disturbance Perceptual disturbance

Common Causes of BPSD Overwhelmed – overstimulated Underwhelmed – understimulated Cognition  mood behavior

Examples of Behavioral Dyscontrol Combativeness Verbal aggression Disrobing Wandering Repetitive behaviors

Examples of Mood Disturbance Depression Anxiety Emotional restlessness Apathy

Examples of Perceptual Disturbance Delusions Hallucinations Bizarre thoughts

What is Meaningful Engagement? Involves Four Features: an interpersonal interaction involving the resident/patient and one or more other people present-focused, with an emphasis on the here-and-now the subject or content of the interaction is meaningful to the resident (i.e., patient can relate to it) the activity activates preserved memories

How Meaningful Engagement Activities Reduce BPSDs Meets a social need Activates cognitive processes Connects participants to meaningful personal content Addresses disparity between stimulation and cognitive resource

MCI Today, Dementia Tomorrow: Improving Clinical Strategies Presented by Dr. William Mansbach CEO & Founder, Mansbach Health Tools, LLC www.thebcat.com