A preliminary study on the use of the Boston Cognitive Assessment to assess cognitive function in a Chinese population

doi:10.21203/rs.3.rs-4821369/v1

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Research Article

A preliminary study on the use of the Boston Cognitive Assessment to assess cognitive function in a Chinese population

https://doi.org/10.21203/rs.3.rs-4821369/v1

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Background

This study explored the reliability and validity of the Boston Cognitive Assessment (BOCA) in a healthy China population to obtain an objective basis for its application in China.

Methods

In total, 111 healthy individuals were recruited as research participants from Changzhou Prefecture from December 2023 to July 2024. The Mini-Mental State Examination (MMSE) was conducted offline with paper and pen, whereas the BOCA self-assessment scale was conducted online. The correlation, internal consistency, test–retest reliability, content validity, and calibration validity were analyzed based on the relevant data.

Results

Age was moderately negatively correlated with BOCA scores, while length of education was moderately positively correlated with BOCA scores. The overall Cronbach’s α coefficient of the BOCA scale was 0.774, indicating good internal consistency. The intra-group correlation coefficient (ICC) of the total scores was 0.796, indicating good test–retest reliability. The correlation coefficient between the scores of each BOCA item and the total score was between 0.202 and 0.751 (P < 0.05), indicating good content validity. A moderate positive correlation was found between the total BOCA and MMSE scores (r = 0.682, P < 0.01), indicating good calibration validity.

Conclusions

The BOCA scale has good reliability and validity, indicating its reliability in comprehensively and effectively assessing cognitive function in healthy people in China, and thus it can be used as a remote cognitive self-assessment tool for the Chinese population.

Boston Cognitive Assessment

Healthy population

Effectiveness

Reliability

China has the largest population in the world that is currently facing a significant aging problem. The seventh population census showed that more than 190 million people in China are over 65 years, accounting for 13.5% of the total population. With the increase in the population age, the prevalence of cognitive impairment also increases. Some surveys indicate that the prevalence of dementia in the population aged > 65 years is 5.14% [1], while the prevalence of mild cognitive impairment is 20.8% [2]. Cognitive impairment is becoming a serious public health problem in China, posing a significant socioeconomic burden [3, 4]. No effective drugs are currently available to cure or reverse cognitive impairment; however, early detection facilitates early diagnosis and sufficient intervention to slow the progression of cognitive impairment [5–7]. The consensus group of the International Association of Gerontology and Geriatrics-Global Aging Research Network emphasized the importance of the early recognition of cognitive impairment and affirmed that screening by medical staff is an important step toward maintaining the brain health of aging populations around the world [8].

Currently the most widely used cognitive screening scales include the Mini-Mental State Examination (MMSE) [9, 10] and Montreal Cognitive Assessment (MoCA) [11]. However, both tools are traditional paper-and-pen tests that largely rely on professional medical staff and utilize a large amount of human and material resources [12]. Furthermore, the participants need to physically attend the designated medical location, resulting in some people losing the evaluation opportunity because of traffic/walking difficulties and the restrictions imposed by epidemic outbreaks [13]. In addition, the content of these cognitive assessments is fixed, when applied to long-term longitudinal cognitive monitoring, the practice effect will interfere with the assessment results [14]. Therefore, a self-managing cognitive screening tool needs to be developed for effective and reliable longitudinal monitoring of overall cognitive status.

The Boston Cognitive Assessment (BOCA) was designed by Professor Andrey Vyshedskiy et al. of Boston University. It is an internet-based, computerized, and remote self-management cognitive assessment tool. Subjects can click the test instructions and test links sent by medical workers through the internet and complete the cognitive assessment at home or remotely after reading the short test instructions. The scale covers multiple cognitive domains and comprehensively reflects the cognitive status of participants. Tasks are randomly selected and nonrepetitive, minimizing the practice effect. Therefore, the BOCA scale could be used for longitudinal monitoring of the overall cognitive status. In the preliminary validation study of the BOCA scale, Dov et al. [15] enrolled outpatients of a neuropsychological clinic in eastern Massachusetts and compared the BOCA scale with the Telephone Interview for Cognitive Status (TICS). The study confirmed that the BOCA scale had good internal consistency, test–retest reliability, factor structure, and calibration validity, and it can be used as a screening tool for mild neurocognitive impairment and be incorporated into home self-management or clinical care. In a follow-up study of the BOCA scale, Andrey et al. [16] enrolled participants from geriatric and memory clinics in eastern Massachusetts and Washington, DC, and compared the BOCA scale with the MoCA scale to further verify the former’s reliability and validity in a larger population. The study found that the BOCA had higher sensitivity and specificity for mild cognitive impairment. At present, the feasibility of applying the BOCA scale to the Chinese population is still unclear. Evaluation of the BOCA scale in the healthy population in China can determine the reliability and accuracy of the cognitive function test in the cultural background of China, and further promote its application in the Chinese stroke population to clarify the field and degree of cognitive impairment, establish the correct rehabilitation treatment, and determine the curative effect and prognosis of patients. Therefore, in this study, the MMSE scale was used as the calibration standard to explore the reliability and validity of the BOCA scale in healthy people in China, so as to obtain a solid scientific basis for its application in China.

2.1. Participants

To facilitate the conduct of an under-the-line and across-the-line assessment of the MMSE, healthy subjects from the Changzhou Prefecture were recruited between December 2023 and July 2024.

Inclusion criteria: (1) Age ≥ 18 years old; (2) in good health, with no previous central nervous system conditions, such as stroke, cerebral trauma, Parkinson’s disease, and dementia; (3) no serious audio-visual disorder and having the ability to participate in the test; (4) having the ability to independently complete online evaluation operations; and (5) agreement to participate in the study and sign the informed consent form.

Exclusion criteria: (1) a history of brain disease that may affect cognitive function; (2) presence of severe internal and surgical diseases and unstable vital signs; (3) refusal to participate in this study.

In total, 150 healthy participants were included in the study. Of these, 39 participants dropped out, bringing the final number to 111 participants, including 41 men and 70 women. The age of the participants ranged from 19 to 79 years, and four age groups were organized: 65 participants aged 18–39 years, 29 participants aged 40–59 years, and 17 participants aged 60–79 years. The range of years of schooling was 3–16 years, and the participants were grouped according to length of schooling: 10 participants ≤ 6 years, 17 participants from 7 to 9 years, 16 cases from 10 to 12 years, and 68 cases ≥ 13 years (Table 1).

Table 1

General data of study participants (n = 111)
Project		Number of cases	Constituent ratio (%)
Sex	Male	41	36.9
	Female	70	63.1
Age (years)	18–39	65	58
	40–59	29	25.9
	60–79	17	15.2
Years of education	≤ 6	10	8.9
	7–9	17	15.2
	10–12	16	14.3
	≥ 13	68	60.7

2.2. Evaluation methods

2.2.1. Assessment tools

(1) MMSE: Developed by Folstein et al. [10], the MMSE is a common cognitive function screening scale. The cognitive items evaluated include orientation (10 points); memory (3 points); attention and calculation (5 points); delayed memory (3 points);language and visual space function (9 points in total: naming ability [2 points]; retelling ability [1 point]; three-step instruction [3 points]; reading ability [1 point]; writing ability [1 point]; and copying ability [1 point]). The total score was 30 points. A higher score indicated better cognitive function. In previous studies, the following items were used to define impaired cognitive function according to the cultural level of the subjects [17]: illiteracy ≤ 19 points; primary school ≤ 22 points; and secondary school or above ≤ 26 points.

(2) BOCA: Designed by Professor Andrey Vyshedskiy of Boston University and others [16], the BOCA scale is a remote online test that can be accessed from various devices, such as smartphones, tablets, and computers. It takes approximately 10 minutes to accomplish and is mainly used for long-term monitoring of cognitive function. The scale includes eight subscales: instant memory (2 points); language understanding (5 points); visual spatial reasoning (3 points); executive function (4 points); attention (4 points); calculation (4 points); orientation (3 points); and delayed memory (5 points). The highest possible total score is 30 points. A higher score indicates a stronger cognitive ability. With the exception of orientation-related questions, each scale consists of a set of increasingly difficult questions.

2.2.2. Assessment process

First, offline evaluation with the MMSE scale was conducted, and the online evaluation using the BOCA scale was performed after 24–48 h. 1 month after completing the first BOCA scale evaluation, a second online re-evaluation of the BOCA scale was conducted.

The offline MMSE assessment was held in a quiet room and conducted by rehabilitation physicians trained in the scale and familiar with the assessment methods. The online evaluation with BOCA was arranged in the participant’s home. The rehabilitation physician sent the test description and test link of the BOCA scale to the subject through the Internet, and informed each subject to read the test description in detail and then to click the test link to begin the evaluation. The test instructions of the BOCA scale included: ① a quiet environment; ② Conducting checks for the computer audio settings before the test to ensure that the computer instructions can be heard clearly; ③ Completing the test independently without seeking help; and ④ Refraining from using tools, such as paper and pen, during the test.

2.3. Statistical analysis

SPSS version 26.0 was used for statistical analysis. Non-parametric tests were performed to compare the differences in scores among the sexes and the different age and education groups. Spearman’s test was used to analyze the correlations between age, length of education and BOCA scores. The Cronbach’s α coefficient was used to evaluate the reliability of internal consistency, and the intra-group correlation coefficient (ICC) was used to evaluate the test–retest reliability. The correlation analysis of each score and the total score was used to assess the content validity, while the Spearman’s test was used to compare the BOCA and MMSE total scores and the scores in the corresponding subdomains of the two scales, and the correlation coefficient was calculated to evaluate the calibration validity.

3.1. MMSE and BOCA scores

The median (upper quartile–lower quartile) of MMSE scores for the 111 healthy participants was 30 (29–30) points, and the median (upper quartile–lower quartile) of BOCA scores was 28 (25–29) points.

3.2. Comparison of MMSE and BOCA scores between different groups, and the correlations between demographic characteristics and scores

The MMSE and BOCA scores of the different age groups differed significantly (P < 0.01). The pairwise comparison revealed that the MMSE and BOCA scores differed significantly between the 18–39 and 40–59 years old groups, as well as between the 18–39 and 60–79 years old groups. No significant difference was found between the 40–59 and 60–79 years old groups (Table 2).

Table 2

MMSE and BOCA scores of groups according to age bracket
	18–39 years	40–59 years	60–79 years	Inter-group variance (p-value)
	18–39 years	40–59 years	60–79 years	18–39 years and vs. 40–59 years	18–39 years vs. 60–79 years	40–59 years vs. 60–79 years
MMSE score	30(30–30)	29(28–30)	28(27–29)	<0.001	<0.001	0.068
BOCA score	29(27.5–30)	27(24–28)	24(22–25)	<0.001	<0.001	0.135

MMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.

The MMSE and BOCA scores differed significantly among the groups based on length of education (P < 0.01). The comparison showed that MMSE and BOCA scores differed significantly among the different length of education groups, particularly between ≥ 13 and ≤ 6 years, ≥ 13 and 7–9 years, and ≥ 13 and 10–12 years. No significant differences were observed among ≤ 6 years, 7–9 years and 10–12 years (Table 3).

Table 3

MMSE and BOCA scores of groups based on length of education
–	≤ 6 years	7–9 years	10–12 years	≥ 13 years	Inter-group variance (p-value)
–	≤ 6 years	7–9 years	10–12 years	≥ 13 years	≤ 6 years vs 7–9 years	≤ 6 years vs. 10–12 years	≤ 6 years vs. ≥13 years	7–9 years vs. 10–12 years	7–9 years vs. ≥13 years	10–12 years vs. ≥13 years
MMSE score	28(25.5–29)	28(27 − 29)	29.5(28 − 30)	30(30 − 30)	1.000	0.165	<0.001	0.164	<0.001	0.019
BOCA score	23(19.25 − 24)	25(21 − 26.5)	27(23.25 − 28)	29(28 − 30)	1.000	0.269	<0.001	0.284	<0.001	0.001

MMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.

A moderate negative correlation was found between age and both total MMSE (r = − 0.605, P < 0.01) and BOCA scores (r = − 0.676, P < 0.01). The length of schooling was moderately positively correlated with both total MMSE (r = 0.641, P < 0.01) and BOCA (r = 0.689, P < 0.01) scores.

3.3. Reliability analysis

3.3.1 Internal consistency

The overall Cronbach’s α coefficient of the BOCA scale was 0.774, indicating high internal consistency.

3.3.2 Test–retest reliability

The intra-group correlation coefficient of the overall test–retest reliability was 0.796. The test–retest reliability of each item (except for clock test/execution function and orientation) was good, and the ICC value > 0.5, confirming the good test–retest reliability of the scale (Table 4).

Table 4

ICC values of subscales scores and total scores for the BOCA scale on the first and second evaluations
Subscale	ICC	P
Memory/immediate memory	0.586	<0.001
Language/forehead synthesis	0.677	<0.001
Visual spatial reasoning/mental rotation	0.699	<0.001
Executive function/clock testing	0.402	0.001
Attention	0.568	<0.001
Mental arithmetic	0.563	<0.001
Orientation	0.491	<0.001
Memory/delayed memory	0.65	<0.001
Aggregate score	0.796	<0.001

ICC, intra-group correlation coefficient; BOCA, Boston Cognitive Assessment.

3.4. Validity analysis

3.4.1. Content validity

The correlation coefficient between the score of each BOCA subscale and the total BOCA scale score as between 0.202 and 0.751 (Table 5). Mental arithmetic and orientation were weakly correlated with the total score, while memory/immediate memory, visual spatial reasoning/mental rotation, executive function/clock test, and memory/delayed memory were moderately correlated with the total score, and attention was strongly correlated with the total score.

Table 5

Correlation coefficients between the subscale scores and total score for the BOCA scale
Subscale	r	P
Memory/immediate memory	0.498	<0.01
Language/forehead synthesis	0.751	<0.01
Visual spatial reasoning/mental rotation	0.584	<0.01
Executive function/clock testing	0.605	<0.01
Attention	0.715	<0.01
Mental arithmetic	0.388	<0.01
Orientation	0.202	<0.05
Memory/delayed memory	0.437	<0.01

BOCA, Boston Cognitive Assessment.

3.4.2. Calibration validity

The correlation coefficient between the total BOCA and MMSE scores was 0.682 (P < 0.01), showing a moderate positive correlation. Correlation analysis between the eight cognitive domains of the BOCA scale and the evaluation results of the corresponding MMSE cognitive domains also revealed a moderate positive correlation (Table 6).

Table 6

Correlation coefficients of the BOCA and MMSE scores of corresponding sub-cognitive domains
Subscale	r	P
Memory/immediate memory vs. memory ability	0.404	<0.01
Language/forehead synthesis vs. attention and computational power	0.529	<0.01
Attention vs. attention and computational power	0.571	<0.01
Directional vs. directional force	0.700	<0.01

MMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.

The incidence of cognitive impairment increases with age. The Chinese society is currently at the stage of rapid aging; thus, cognitive impairment is expected to become a serious social problem [18]. Cognitive impairment places a heavy burden on patients, the society, and the country [19, 20]. Early recognition facilitates timely diagnosis, thereby guiding treatment and improving the quality of life [21–23]. Therefore, longitudinal monitoring of cognitive function is particularly important.

Current screening for cognitive function mainly depends on neuropsychological scales such as MMSE and MoCA. Although these scales are verified to have good sensitivity and specificity for cognitive impairment [24–26], they are still beset by problems. First, the professional threshold is high, and the evaluation needs to be conducted by professional doctors or therapists who have received systematic training. The number of qualified physicians in China is seriously insufficient to conduct a large-scale screening [27]. Second, the evaluation conditions require subjects to be physically present at the designated medical place. This can be problematic for older people who would be hindered by distance or inconvenient movement, forcing them to give up the opportunity to get cognitive screening [28]. Third, a fixed form and content create a practice effect with repeated or long-term use, resulting in deviations in assessment results and inapplicability to long-term cognitive monitoring [29, 30]. To address this, Professor Andrey Vyshedskiy et al. developed the BOCA scale as an online self-test tool for longitudinal cognitive assessment, which can be remotely accessed across multiple devices, such as mobile phones, tablets, and computers. The test presents nonrepetitive tasks randomly selected to minimize the practice effect.

Foreign studies have suggested that the BOCA scale is an effective and reliable cognitive evaluation tool that can comprehensively analyze cognitive characteristics and effectively screen for cognitive disorders. In 2021, Dov et al. [15] used the BOCA scale to assess 43 outpatients at a neuropsychological clinic in eastern Massachusetts using the TICS as the calibration, providing a preliminary basis for the reliability and effectiveness of the BOCA scale as a screening tool for mild neurocognitive impairment diseases. In 2022, Andrey et al. [16] enrolled 50 patients with cognitive impairment and 50 healthy control participants recruited from Geriatrics and Memory Clinics in eastern Massachusetts and Washington, D.C., to further verify the reliability and validity of the BOCA scale in a larger group using the MoCA as the calibration. Ferguson et al. [31] evaluated the psychometric characteristics of BOCA and found that age was an important predictor of the total BOCA score. No relevant studies on BOCA have been conducted with Chinese study populations. This is the first research report that used the BOCA scale to evaluate a Chinese cohort.

In this study, the subjects were grouped according to age and length of education to compare the differences in BOCA scores between groups, and then analyzed the correlations between BOCA scores and age or length of education. The results showed significant differences in BOCA scores among different age groups, and a moderate negative correlation was observed between age and BOCA score. The possible causes identified were as follows: brain capacity decreases with age [32], age-related brain structure accelerates degradation [33], the effectiveness of dopamine neurotransmission decreases, and the responses in the dominated brain functional area are delayed [34], leading to different degrees of cognitive decline and, thus, lower cognitive function scores. Significant differences in BOCA scores were also observed among groups with different lengths of education, with a moderate positive correlation between the length of education and BOCA scores, which could be due to several possible reasons. First, higher educational levels can help improve individual cognitive reserve [35, 36], which can effectively stimulate neural ability and improve individual tolerance to neuropathological changes [37, 38], thereby delaying cognitive aging. Second, the completion of the scale requires basic literacy skills. A lengthier education enables individuals to receive more systematic education, which in turn increases their accuracy of comprehension of the test questions. In addition, the BOCA scale is accessed by operating mobile phones, tablets, computers, and other compatible devices. A longer education enriches a person’s skills in operating technology, which in turn improves test performance.

The overall Cronbach’s α coefficient of the BOCA scale was 0.774, indicating that the scale had good internal reliability. In comparison, the Cronbach’s α coefficient in the Dov et al. study was 0.81, while that in the Andrey et al. study was 0.87. The values obtained in the present study were slightly lower than those obtained in the studies with Dov and Andrey, which could be due to population heterogeneity. The language of the original system for scale development was English, and the mother tongue of the subjects in the previous studies was English, which facilitated their understanding of the test questions. In contrast, the subjects in the present study all spoke Chinese as their mother tongue, and the BOCA scale was translated for them. Some translational deviations from the original semantic expressions may have occurred, which would have affected the subjects’ understanding of the test questions, leading to measurement errors.

Forty subjects were randomly selected in the study. After 1 month, the participants were evaluated again. The results showed that the overall test–retest reliability was good, with an intra-group correlation coefficient of 0.796.

The content validity was assessed by analyzing the correlations between each item and the total score. The results showed a moderate to strong correlation between the item and the total score except for a weak correlation between the total score and the mental arithmetic and orientation subscales, indicating that the content validity was good. The mental arithmetic subscale consists of four difficult-to-easy calculation questions. The scoring standard is 1 point for every correct answer, and the highest possible total score is 4 points. The questions are shown on the computer. Due to the slow broadcasting speed of the questions, some patients became impatient and hastily performed the calculations, causing them to become careless and choose the wrong answers, resulting in a low correlation between the mental arithmetic score and the total score. The orientation subscale consisted of three questions. The subjects were asked about the year, month, and week, and one correct answer was scored 1 point, totaling three points. The question design highly coincided with the time-oriented question in MMSE. Since the BOCA and MMSE scales were only completed within an interval of 24–48 h between each other, and the MMSE scale was completed before the BOCA scale, some subjects would ask about the orientation results after completing the MMSE scale and would thus be told the correct answers. Consequently, this affected the authenticity of the scores of the orientation questions in the BOCA scale and further affected the correlation between the orientation score and the total score.

The MMSE scale was used as the calibration scale to verify the calibration validity of the BOCA scale. The correlation between the total scores of the BOCA scale and the calibration total scores was moderate, while the correlation between the scores of the BOCA and MMSE sub-cognitive domains was also moderate, indicating that the scale had good calibration validity.

The disadvantages of this study lie in that the research subjects were all healthy people without diseases that affect cognition, and the research participants were monotonous. Hence, subsequent clinical studies involving patients with stroke, cerebral trauma, and other neurological diseases should be conducted to further verify the effectiveness of the BOCA scale.

In summary, the BOCA scale has good reliability and validity in consideration of the cultural background of China. Thus, it can be effectively used for remote self-assessment of cognitive function in Chinese population and comprehensively reflect the overall cognitive level of the participants. Thus, this study recommends the use of the BOCA scale in China.

BOCA Boston Cognitive Assessment

ICC Intra-group correlation coefficient

MMSE Mini-Mental State Examination

MoCA Montreal Cognitive Assessment

TICS Telephone Interview for Cognitive Status

Ethics approval and consent to participate

The study was approved by the Third Affiliated Hospital of Soochow University. Informed consent was obtained from all the participants. All methods were performed in accordance with relevant guidelines and regulations. It was performed in consonance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The article is funded by a grant from the 2022 Jiangsu Province Elderly Health Research Program (Project No. LKM2022051) and the 2023 Changzhou Applied Basic Research Top Project (Project No. CJ20230060).

Authors’ contributions

Designing study: Jiahui Ding, Yehuan Wu, Jianan Zhang, Ya Wang. Recruiting the samples: Jiahui Ding, Jing Guo, Yue Shi. Analyzing the datas: Jiahui Ding, Ying Tang, Xiaoxia Gao, Ya Wang. Drafting the manuscript: Jiahui Ding, Xiaofang Yuan, Xiao Fei. Revising the manuscript: Jiahui Ding, Yi Zhang. All authors reviewed the final manuscript.

Acknowledgements

We thank all participants of the survey.

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No competing interests reported.

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02 Aug, 2024
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30 Jul, 2024
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A preliminary study on the use of the Boston Cognitive Assessment to assess cognitive function in a Chinese population

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

1. Background

2. Methods

2.1. Participants

2.2. Evaluation methods

2.2.1. Assessment tools

2.2.2. Assessment process

2.3. Statistical analysis

3. Results

3.1. MMSE and BOCA scores

3.3. Reliability analysis

3.3.1 Internal consistency

3.3.2 Test–retest reliability

3.4. Validity analysis

3.4.1. Content validity

3.4.2. Calibration validity

4. Discussion

5. Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1