Value of Cognitive Assessment and Brain Fitness for Improving Memory and Preventing Behavioral Disturbances Presented by Susan Kraus, MSN, CRNP-PMH, CRNP-A Faculty, The BCAT 1

Neuro-Cognitive Domains 2

The basics of primary neuro-cognitive domains in everyday living Structure-function Neurons Basic brain structures NEURO-COGNITIVE DOMAINS 3

Basic Brain Structures Whole Brain 4 NEURO-COGNITIVE DOMAINS

Basic Brain Structures Frontal Lobes Executive Processes 5 NEURO-COGNITIVE DOMAINS

Basic Brain Structures Temporal Lobes Learning & Memory 6 NEURO-COGNITIVE DOMAINS

Basic Brain Structures Parietal Lobes Attentional Awareness of the Environment 7 NEURO-COGNITIVE DOMAINS

Basic Brain Structures Hippocampus Early Memory Stage 8 NEURO-COGNITIVE DOMAINS

Contextual memory The case of story recall Executive functions The case for executive controls Attentional capacity The case for attention as “the oil” The Three Central Cognitive Domains (The Cognitive Task Manager) 9 NEURO-COGNITIVE DOMAINS

Utility of Cognitive Screening Tools 10

We have an aging society with associated problems. As people live longer, the incidence/prevalence of dementia rates increase. Over 5 million people have Alzheimer’s disease (AD), anticipated to be 13 million by Numbers are vastly greater if you include other dementias and people with Mild Cognitive Impairment (MCI). UTILITY OF COGNITIVE SCREENING TOOLS The utility of cognitive screening tools 11

U.S. Preventive Services Task Force Statement Routine screening versus screening when there is a subjective or objective memory complaint Age as risk factor and screening for people over 80 The special case of MCI and dementia conversion (10- 15% annually) When to use screening tools 12 UTILITY OF COGNITIVE SCREENING TOOLS

Aide in diagnosis Early recognition enhances efficacy of treatments Improve disease management and planning Identify functional issues Manage expectations of patients, families, providers, staff Time and cost effective Lowers patient resistance and encourages compliance Uses of screening tools 13 UTILITY OF COGNITIVE SCREENING TOOLS

What should a good cognitive screening tool be able to do? Administered by professionals and techs Completed in less than 15 minutes (sometimes five minutes) Able to differentiate between MCI and dementia Broadly assess memory skills Broadly assess executive skills Assess attentional skills Predict ADLs & IADLs 14 UTILITY OF COGNITIVE SCREENING TOOLS

Mini-Mental State Examination (MMSE) Short Test of Mental Status (STMS) Montreal Cognitive Assessment (MoCA) Saint Louis University Mental Status Examination (SLUMS) Brief Cognitive Assessment Tool (BCAT) & BCAT-SF COMMONLY USED SCREENING TOOLS Commonly used cognitive screening tools 15

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 MMSE (Folstein, Folstein, & McHugh, 1975) 16 COMMONLY USED SCREENING TOOLS

Verbal features are more complex than MMSE Relatively poor sensitivity to MCI STMS (Kokmen et al., 1987) 17 COMMONLY USED SCREENING TOOLS

Sensitive to cognitive spectrum Designed primarily for frontline providers Relatively weak on memory No story recall component Stronger on executive functions, but no complex reasoning item MoCA (Nasreddine et al., 2005) 18 COMMONLY USED SCREENING TOOLS

Sensitive to cognitive spectrum Designed primarily for frontline providers Has a story recall, but no free recall or delayed recall Has complex reasoning, but no cognitive set-shifting SLUMS (Tariq et al., 2006) 19 COMMONLY USED SCREENING TOOLS

Four studies, starting in items, 50 maximum points minutes in administration Has a MCI versus dementia “cut” score (37/38) Has score ranges for cognitive categories Has three cognitive “clusters” Predicts ADL & IADL Website-based scoring program BCAT (Mansbach, MacDougall, & Rosenzweig 2012) 20 COMMONLY USED SCREENING TOOLS

BCAT Test 21 THE BCAT

BCAT Item Detail 22 BCAT ITEM DETAIL

BCAT Item Detail 23 BCAT ITEM DETAIL

BCAT Item Detail 24 BCAT ITEM DETAIL

BCAT Item Detail 25 BCAT ITEM DETAIL

BCAT Item Detail 26 BCAT ITEM DETAIL

BCAT Item Detail 27 BCAT ITEM DETAIL

BCAT: The 3 Clusters 1. Contextual Memory Immediate Story Recall Delayed Story Recall Story Recognition Orientation example “Carol borrowed $10 from her brother Jack last week. She couldn’t pay him back because she bought a delicious ice cream cone at the circus.” 28 THE THREE CLUSTERS

BCAT: The 3 Clusters 2. Executive Functions Verbal Trails (OTMT) Mental Control (days of the week, backward) Judgment Arithmetic Reasoning Digits Backward example “Suppose you have a 1 PM appointment with your doctor. It takes 45 minutes to get there. What time is the latest you can leave to get there at 1 PM?” 29 THE THREE CLUSTERS

BCAT: The 3 Clusters 3. Attentional Capacity Immediate Word List Naming Letter List example Banana… Justice… Sara… Bridge… 30 THE THREE CLUSTERS

BCAT Scoring Program 31

Computer-assisted scoring Total score & Factor scores Clinical considerations Report that can be printed and/or ed BCAT SCORING PROGRAM BCAT Scoring & Interpreting 32

BCAT CROSSWALK TO FUNCTIONAL STATUS Adapted by Dr. William Mansbach from Mansbach, W. E., MacDougall, E. E., & Rosenzweig, A. S. (2012). The Brief 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), Note: The score ranges reported above are general guidelines based on descriptive statistics from the normative study. They should not be interpreted as absolutes. The cognitive stages, test score ranges, and cognitive/functional descriptions are not always distinct, but can overlap. The cognitive stages are determined by plus/minus one standard deviation (SD) from the mean in each category. Modest adjustments were then made based on the entire neuropsychological batteries administered. The primary purpose of presenting cognitive stages is to use them as a tool for managing function. 33

BCAT CROSSWALK WITH MMSE & GDS Adapted by Dr. William Mansbach from 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), ; Reisberg, B., Ferris, S. H., de Leon, M. J., & Cook, T. (1982). The global deterioration scale for the assessment of primary degenerative dementia. American Journal of Psychiatry, 139, ; & Mansbach, W. E., MacDougall, E. E., & Rosenzweig, A. S. (2012). The Brief 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), Note: The score ranges reported above are general guidelines based on descriptive statistics from the normative study. They should not be interpreted as absolutes. The cognitive stages, test score ranges, and cognitive/functional descriptions are not always distinct, but can overlap. The cognitive stages are determined by plus/minus one standard deviation (SD) from the mean in each category. Modest adjustments were then made based on the entire neuropsychological batteries administered. The primary purpose of presenting cognitive stages is to use them as a tool for managing function.

Practical recommendations Rehab focus Value of cognitive exercises as determined by BCAT scores Brain fitness It’s all about function 35 FUNCTION

Cognitive stimulation Four criteria – Moderately difficult – Frequent – Novel – Engaging – (Social) …. For some What is Brain Fitness BRAIN FITNESS 36

Neurons and how they communicate Neuroplasticity Cognitive Reserve How Does Brain Fitness Work? HOW DOES BRAIN FITNESS WORK 37

In SNF: – More than 3.3 million people – 70-75% have cognitive impairment – Roughly 30% mild, 25% moderate, 20% severe In ALF: – 50-70% have dementia (especially Alzheimer’s) – In our studies, 80% & 2/3 of them have MCI to mild dementia What Value Does Brain Fitness Bring? VALUE OF BRAIN FITNESS 38

Correlations between cognitive impairment and behavioral and mood issues Under-stimulation, over-stimulation problems Brain Fitness can engage resident in purposeful activity For MCI and mild dementia, it can improve cognitive and mood functioning (if person-centered) Can reduce behavior problems More on Value… VALUE OF BRAIN FITNESS 39

Types & Brands of Brain Fitness BRANDS OF BRAIN FITNESS 40

Begins with BCAT cognitive assessment – Can be administered by tech or professional – Determines which modules and level of difficulty “Cognitive Task Manager” – Memory – Executive functions – Attention capacity myBCAT BRAIN FITNESS PROGRAM 41

For more information about the BCAT Test System, visit 42

Utilize the automated online BCAT test. Access the most current clinical research, news, and treatments about memory loss. Take advantage of continuing education courses for healthcare professionals. Receive weekly s with links to the Mind & Memory Blog and the latest articles for healthcare professionals. It’s FREE to Register Go to and register today! 43