Presented by Susan Kraus, MSN, CRNP-PMH, CRNP-A Faculty, The BCAT

1. 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

2. Neuro-Cognitive Domains

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

4. Basic Brain Structures Whole Brain NEURO-COGNITIVE DOMAINS

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

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

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

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

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

10. Utility of Cognitive Screening Tools

11. The utility of cognitive screening tools 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 2050. Numbers are vastly greater if you include other dementias and people with Mild Cognitive Impairment (MCI). UTILITY OF COGNITIVE SCREENING TOOLS

12. When to use screening tools 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) UTILITY OF COGNITIVE SCREENING TOOLS

13. Uses of 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 UTILITY OF COGNITIVE SCREENING TOOLS

14. 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 UTILITY OF COGNITIVE SCREENING TOOLS

15. Commonly used 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

16. 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 COMMONLY USED SCREENING TOOLS

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

18. MoCA (Nasreddine et al., 2005) • 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 COMMONLY USED SCREENING TOOLS

19. SLUMS (Tariq et al., 2006) • 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 COMMONLY USED SCREENING TOOLS

20. BCAT (Mansbach, MacDougall, & Rosenzweig 2012) • Four studies, starting in 2005 • 21 items, 50 maximum points • 10-15 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 COMMONLY USED SCREENING TOOLS

21. BCAT Test THE BCAT

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 ITEM DETAIL

28. BCAT: The 3 Clusters1. Contextual Memory • Immediate Story Recall • Delayed Story Recall • Story Recognition • Orientation “Carol borrowed $10 from her brother Jack last week. She couldn’t pay him back because she bought a delicious ice cream cone atthe circus.” example THE THREE CLUSTERS

29. BCAT: The 3 Clusters2. Executive Functions • Verbal Trails (OTMT) • Mental Control (days of the week, backward) • Judgment • Arithmetic Reasoning • Digits Backward “Suppose you have a 1 PM appointment with your doctor. It takes45 minutes to get there. What time is the latest you can leave toget there at 1 PM?” example THE THREE CLUSTERS

30. BCAT: The 3 Clusters3. AttentionalCapacity • Immediate Word List • Naming • Letter List Banana… Justice… Sara… Bridge… example THE THREE CLUSTERS

31. BCAT Scoring Program

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

33. 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), 183-194. 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.

34. 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), 189-198; 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, 1136-1139; & 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), 183-194. 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.

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

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

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

38. 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

39. 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

40. Types & Brands of Brain Fitness • BRANDS OF BRAIN FITNESS 40

41. 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

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