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

2. Highlights on Prevalence
Over 5 million Americans have Alzheimer’s disease (AD), anticipated to be 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

3. 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

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

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

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

7. 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

8. 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.

9. 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

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

11. 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)

12. 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

13. 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

14. 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

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

16. “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

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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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)

25. 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

26. 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

27. 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

28. 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

29. 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

30. Meaningful Engagement as a Care Intervention

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

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

33. Examples of Behavioral Dyscontrol
Combativeness
Verbal aggression
Disrobing
Wandering
Repetitive behaviors

34. Examples of Mood Disturbance
Depression
Anxiety
Emotional restlessness
Apathy

35. Examples of Perceptual Disturbance
Delusions
Hallucinations
Bizarre thoughts

36. 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

37. 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

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