The German version of the tablet-based UCSF Brain Health Assessment is sensitive to early symptoms of neurodegenerative disorders

Abstract

Introduction : Cognition often remains unassessed in primary care. To improve early diagnosis of neurocognitive disorder (NCD) in Switzerland, the tablet‐based UCSF brain health assessment (BHA) and brain health survey (BHS) were validated.
Methods : The German BHA, BHS, and Montreal Cognitive Assessment (MoCA) were administered to 67 patients with mild/major NCD and 50 controls. BHA includes subtests of memory, executive, visuospatial, and language functioning, and informant‐based BHS asks about behavior and motor functioning.
Results : The complete instrument (BHA + BHS) was most accurate at detecting mild NCD (AUC = 0.95) and NCD without amyloid pathology (AUC = 0.96), followed by the BHA. All measures were accurate (all AUCs > 0.95) at distinguishing major NCD and NCD with amyloid pathology (Alzheimer's disease [AD]) from controls.
Discussion : The German BHA and BHS are more sensitive to mild NCD and non‐AD presentations than the MoCA and thus have a high potential to identify patients with NCD in primary care earlier than currently used screens.

Full text

Received: 21 June 2023 Revised: 30 October 2023 Accepted: 2 November 2023
DOI: 10.1002/brb3.3329
ORIGINAL ARTICLE
The German version of the tablet-based UCSF Brain Health
Assessment is sensitive to early symptoms of
neurodegenerative disorders
Toller Gianina1Stäger Lorena1Kumurasamy Dilaxy1Callahan Patrick2
Köhn Florian3Münzer Thomas3Kunze Ursi4U. Monsch Andreas4
Possin Kate2Katherine P. Rankin2Ansgar Felbecker1
1Department of Neurology, Kantonsspital St.
Gallen, Gallen, Switzerland
2Memory and Aging Center, University of
California San Francisco, San Francisco,
California, USA
3Geriatrische Klinik St. Gallen, Gallen,
Switzerland
4Memory Clinic, University Department of
Geriatric Medicine Felix Platter, Basel,
Switzerland
Correspondence
Gianina Toller, Cantonal Hospital of St. Gallen,
Department of Neurology, Rorschacher
Strasse 95, 9000 St. Gallen, Switzerland.
Email: gianina.toller@lups.ch
Funding information
Cantonal Hospital of St. Gallen This research
work was financially supported by KSSG
research grant (number, Grant/Award
Number: 20/33
Abstract
Introduction: Cognition often remains unassessed in primary care. To improve early
diagnosis of neurocognitive disorder (NCD) in Switzerland, the tablet-based UCSF
brain health assessment (BHA) and brain health survey (BHS) were validated.
Methods: The German BHA, BHS, and Montreal Cognitive Assessment (MoCA) were
administered to 67 patients with mild/major NCD and 50 controls. BHA includes
subtests of memory, executive, visuospatial, and language functioning, and informant-
based BHS asks about behavior and motor functioning.
Results: The complete instrument (BHA +BHS) was most accurate at detecting mild
NCD (AUC =0.95) and NCD without amyloid pathology (AUC =0.96), followed by the
BHA. All measures were accurate (all AUCs >0.95) at distinguishing major NCD and
NCD with amyloid pathology (Alzheimer’s disease [AD]) from controls.
Discussion: The German BHA and BHS are more sensitive to mild NCD and non-AD
presentations than the MoCA and thus have a high potential to identify patients with
NCD in primary care earlier than currently used screens.
KEYWORDS
cognitive screening, major neurocognitive disorder, mild neurocognitive disorder, primary care,
tablet-based testing
1INTRODUCTION
Primary care providers (PCP) play a key role in the diagnostic process
of neurocognitive disorders because they are often the first to evaluate
patients presenting with progressive changes in cognition and behavior
(Cardarelli et al., 2010), which are among the earliest clinical signs of
neurodegenerative disorders (Ossenkoppele et al., 2015; Seeley et al.,
2005). Despite the importance of early recognition and evaluation of
cognitive and behavioral symptoms, neuropsychological measures that
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Brain and Behavior published by Wiley Periodicals LLC.
are sensitive to early symptoms of typical and atypical neurodegen-
erative diseases are not commonly part of the diagnostic workup in
primary care practices (Giezendanner et al., 2018). Barriers such as lack
of availability, expertise, and logistics prevent physicians from using
such cognitive screening tests (Koch et al., 2010; Sabbagh et al., 2020).
In Switzerland, PCP often use paper-and-pencil tests such as the
mini-mental state examination (MMSE) (Folstein et al., 1975)and
the clock drawing test to screen patients for cognitive deficits, most
of which are not sensitive enough to detect patients with early
Brain Behav. 2023;13:e3329. wileyonlinelibrary.com/journal/brb3 1of8
https://doi.org/10.1002/brb3.3329

2of8 GIANINA ET AL.
neurocognitive disorders (Bally et al., 2021). The Association of Swiss
Memory Clinics recommends PCP to use the Montreal Cognitive
Assessment (MoCA) (Nasreddine et al., 2005) as a cognitive screening
tool in clinical practice because it is more sensitive and specific to early
changes in cognition than other paper-and-pencil-based tests (Bürge
et al., 2018; Pinto et al., 2019). However, despite its good psychomet-
ric characteristics to detect mild neurocognitive disorder, particularly
due to Alzheimer’s disease (AD) (Pinto et al., 2019; Tsoi et al., 2015),
the MoCA has several disadvantages for early diagnosis in primary
care settings including lack of assessment of non-cognitive symptoms
that belong to the first symptoms of atypical non-AD neurodegener-
ative disorders such as frontotemporal dementia, informant ratings,
functional decline, as well as automatic interpretative feedback for
PCP to guide care. To overcome some of these problems, researchers
have recently developed a tablet-based screening tool that includes
a very brief, 10-min cognitive assessment (brain health assessment,
BHA) of four key cognitive domains (memory, executive functioning,
visuospatial functioning, language), and an optional informant survey
(brain health survey, BHS) (Possin et al., 2018). This validation study
conducted in a sample of highly educated, White, and English-speaking
patients in the United States showed that the tablet-based cognitive
assessment (BHA) alone, as well as in conjunction with the informant
survey, shows excellent combined sensitivity and specificity to typ-
ical and atypical presentations of mild neurocognitive disorder and
dementia, outperforming the widely used MoCA (Possin et al., 2018). In
addition, a longitudinal follow-up study demonstrated that the instru-
ment is also sensitive to changes over time, even to verysubtle changes
in healthy individuals with positive amyloid status (Tsoy et al., 2021).
Validation studies in different Western and developing countries are
ongoing, and the first study completed in a Hispanic sample in Cuba
also showed that the BHA remains sensitive and specific to detect early
symptoms of patients with neurodegenerative disorders in that popu-
lation (del Alamo et al., 2003). Our study presents the first validation
study conducted in a German-speaking sample that has the potential to
provide further cross-cultural evidence for the usefulness of the tablet-
based screening tool for early diagnosis and to track cognitive changes
in primary care practices.
In this multi-site study, we translated the BHA and BHS to stan-
dard high German and investigated whether the German version
can also distinguish patients with mild and major neurocognitive
disorder from healthy controls at high sensitivity and specificity.
Based on the results obtained in the English- and Spanish-speaking
samples, we expected that the German version would accurately
indicate early clinical symptoms of individuals with neurocognitive
disorders.
2METHODS
2.1 Participants
This cross-sectional, observational study was conducted at three sites
in Switzerland: the Memory Clinic of the Kantonsspital St. Gallen, the
Memory Clinic of the Geriatrische Klinik St. Gallen, and the Mem-
ory Clinic Universitäre Altersmedizin Felix Platter Spital Basel. We
included 29 patients fulfilling the Diagnostic and Statistical Manual of
Mental Disorders (DSM)-5 (American Psychiatric Association, 2013)
criteria for mild neurocognitive disorder which include evidence of
modest cognitive decline from a previous level of performance in one
or more cognitive domains evidenced by both a concern of the indi-
vidual, an informant, or the clinician, and a modest impairment in
cognitive performance. The diagnostic criteria require that the cog-
nitive deficits do not interfere with the capacity for independence in
everyday activities. In addition, we enrolled 38 patients with major
neurocognitive disorder based on the DSM-5 (American Psychiatric
Association, 2013) criteria. These patients were required to show evi-
dence of cognitive decline from a previous level of performance in
one or more cognitive domains based on both concern of the indi-
vidual, an informant, or the clinician, and a substantial impairment
in cognitive performance. The cognitive symptoms associated with
major neurocognitive disorder interfere with patients’ independence
in instrumental activities of daily living such as paying bills or man-
aging medications. Furthermore, patients with major neurocognitive
disorder fulfilled the research criteria for one of the following clinical
syndromes: AD clinical syndrome (Bennett et al., 2018)(n=19), vas-
cular cognitive disorder (Sachdev et al., 2014)(n=1), mixed pathology
(AD and vascular; n=11), behavioral variant frontotemporal dementia
(n=3) (Rascovsky et al., 2011), semantic variant primary progres-
sive aphasia (n=2) (Gorno-Tempini et al., 2011), nonfluent variant
primary progressive aphasia (n=1) (Gorno-Tempini et al., 2011), or
logopenic variant primary progressive aphasia (n=1) (Gorno-Tempini
et al., 2011). Exclusion criteria for all patients included other neurolog-
ical disorders (e.g., stroke and traumatic brain injury), delirium, severe
psychiatric illnesses (e.g., schizophrenia), alcohol and substance abuse,
being unable to give informed consent due to any reason (e.g., severe
cognitive impairment), and MoCA score ≤10/30.
Patients were recruited either at the Memory Clinic of the Kanton-
sspital St. Gallen (n=55) or at the Memory Clinic of the Geriatrische
Klinik St. Gallen (n=12). Each patient underwent a comprehensive
diagnostic evaluation, including a clinical interview, neuropsychologi-
cal and neurological evaluation, and brain magnetic resonance imaging.
A subset of patients (60 out of 67) received a lumbar puncture to iden-
tify amyloid pathology. The final diagnoses were made by a multidis-
ciplinary team of neurologists, neuropsychologists, and neuroimaging
experts. The team also evaluated patients’ capacity to provide written
informed consent.
In addition to patients with mild and major neurocognitive disorder,
we included a sample of 50 healthy controls recruited from a database
of 3000 healthy individuals at the Memory Clinic Basel. To confirm that
these individuals were cognitively healthy (MoCA score ≥26), the Ger-
man version of the MoCA (Nasreddine et al., 2005) was performed.
Exclusion criteria of the healthy control group were assessed using a
medical questionnaire developed at the Memory Clinic Basel, which
was used to rule out subjective cognitive decline (Jessen, 2014)and
a history of neurological disorders, psychiatric disorders, as well as
alcohol and substance abuse.

GIANINA ET AL.3of8
For each patient and healthy control subject, one relative (e.g.,
spouse, parent, sibling) or close friend who had known the participant
for 5 or more years and was in regular contact with the subject was
enrolled in the study. Informants with neurocognitive or acute psychi-
atric disorders were excluded. This group of relatives was included to
collect informant-based ratings on the BHS. The study was reviewed
and approved by the Swiss Ethics Committees Ostschweiz (EKOS)
and Nord- und Zentralschweiz (EKNZ). Written informed consent was
obtained from all participants and their study partners.
2.2 Behavioral measures
The German BHA, BHS, and MoCA were administered to all patients
and healthy control subjects. The BHA and BHS are programmed in
the TabCAT software developed at the University of California, San
Francisco (UCSF) (https://memory.ucsf.edu/tabcat), available on the
Apple App Store. The BHA, the main outcome measure of this study,
is a 10-min tablet-based cognitive assessment comprising four key
domains (memory, executive functioning, visuospatial functioning, and
language). The Favorites task measures episodic memory and requires
participants to learn associations (four faces each paired with a food
and an animal) in two learning trials. After each trial, each face reap-
pears on the screen, and participants have to recall the food and
animal associated with each face. The task also includes a 10-min
delayed recall and a recognition trial. The Match task is a measure
of executive functioning/processing speed that requires participants
to assign symbols to numbers as quickly as possible within 2 min.
In the Line Orientation task, a measure of visuospatial functioning,
participants have to decide which of two target lines is parallel to a
reference line. The difficulty of the Line Orientation task is adaptive,
that is, individually adjusted during the task to precisely fit the perfor-
mance of the participant, and the final score represents the threshold
of the number of degrees of difference a participant can reliably
distinguish, with lower scores reflecting more fine-grained discrimi-
nation. Finally, the Animal Fluency task was used to assess language
skills. Participants were asked to name as many animals as possible
within 1 min (Libon et al., 2009). The number of correct responses,
repetitions, and rule breaks was documented. For the Favorites,
Match, and Animal Fluency tasks, a higher score represents better
performance.
The BHS is an optional informant survey asking 24 questions about
typical cognitive, behavioral, and motor symptoms of neurocognitive
disorders, functional impairment, and rapidity of decline. Informants
were asked to assess changes in cognition, behavior, and motor func-
tioning as well as patients’ functional level within the past 5 years. They
had to rate each question on a Likert scale, which either consisted of
the three response options “yes,” “no,” and “don’t know,” or the four
response options “no change,” “questionably worse,” “a little worse,”
and “much worse.”
To compare the sensitivity to mild neurocognitive disorder between
the tablet-based BHA/BHS and existing paper-and-pencil cognitive
screening tests, the German version of the MoCA (Bartusch & Zip-
per, 2004) was administered to all participants. The MoCA screens
six cognitive domains, including executive and visuospatial function-
ing, attention, language, memory, and orientation for time and place.
The global score ranges between 0 and 30, and a cut-off score ≥26 was
considered cognitively healthy in the original work of Nasreddine et al.
(2005).
2.3 Translations and statistical analyses
The first step of this study was to translate the tablet-based BHA and
BHS to standard high German. Forward and backward translations
were performed by two translators who were proficient in German and
English. All statistical analyses were performed using Statistical Analy-
sis Software (SAS) version 9.4. Group differences in demographic and
clinical variables were examined using linear modeling (PROC GLM).
Group differences in age, sex, and education (which included elemen-
tary and high school, as well as university/academic degrees) were
analyzed using Tukey post hoc tests. Dunnett-Hsu post hoc tests were
used to compare mean least-square scores on the BHA, BHS, and
MoCA between each patient group and the control group. According
to Shapiro–Wilk tests, the distribution in each variable within groups
was not normally distributed. Thus, to ensure the robustness of our
predictions, we used logistic regression analysis instead of discriminant
function analysis to investigate whether the tablet-based BHA/BHS
was able to distinguish (1) patients with mild neurocognitive disor-
der from healthy controls and (2) patients with major neurocognitive
disorder from healthy controls. In a second set of analyses, based on
the results of the lumbar puncture, we divided the entire group of
patients with mild and major neurocognitive disorder into subgroups
of amyloid positive (amyloid+) and amyloid negative (amyloid−)indi-
viduals, and reperformed the logistic regression analyses described
above. We performed these analyses across patients with mild and
major neurocognitive disorder for whom amyloid status was avail-
able (n=60) because our patient subgroups were underpowered to
perform these analyses separately for patients with mild and major
neurocognitive disorder (see Table 1). Similar to the approach used in
Possin et al. (2018), we first converted the raw scores of each BHA
task to z-scores using a regression-based approach adjusting for age,
sex, and education based on the healthy control sample. Regression-
based norms have higher prediction accuracy compared to traditional
norming approaches, particularly for small samples (Van der Elst et al.,
2011). Thus, for each BHA task, we performed multiple linear regres-
sion analysis in the healthy control sample, including the demographic
variables (age, sex, and education) as predictors in each model. For
each patient, we then calculated demographically adjusted z-scores
for each of the four BHA tasks using the formula z=(Y−Y’)/RSE,
where Yis the observed raw score, Y’ is the predicted score derived
from the regression model, and RSE is the residual standard error of
the regression equation. Because higher scores on the Line Orienta-
tion task reflected poorer performance, the z-score calculations for
this task were reversed. To compare the sensitivity and specificity of
the tablet-based assessment and the MoCA, we included the four BHA

4of8 GIANINA ET AL.
TAB LE 1 Demographic and clinical characteristics of the study sample.
Healthy controls Mild neurocognitive disorder Major neurocognitive disorder p-value
Tota l n50 29 38 –
Number of participants with missing BHSadata 3 6 6 –
Number of patients with amyloid status, +/−— 11/11 29/9 –
Age, M(SD) 71.84 ±7.57 73.21 ±8.94 74.42 ±7.47 .316
Sex, female 56% 58.6% 52.6% .884
Education, M(SD) 14.28 ±2.67 13.34 ±3.09 13.05 ±2.79 .107
BHA favorites, M(SD) 16.72 ±4.87 7.31 ±5.37*4.92 ±5.68*<.0001
BHA match, M(SD) 46.24 ±6.03 34.97 ±9.84*30.53 ±11.10*<.0001
BHA line orientation, M(SD) 5.42 ±2.59 6.92 ±4.63 7.86 ±4.82*.016
BHA animal fluency, M(SD) 22.86 ±4.92 17.86 ±4.63*13.74 ±5.47*<.0001
BHS, M(SD) 0.02 ±0.10 0.91 ±1.14*1.47 ±1.54*<.0001
MoCA total score, M(SD) 26.78 ±0.20 22.55 ±3.38*19.74 ±3.81*<.0001
Abbreviations: BHA, brain health assessment; BHS, brain health survey; MoCA, Montreal CognitiveAssessment.
aBHS data were only available for a subset of healthy controls (47 out of 50) and patients with mild (23 out of 29) and major (32 out of 38) neurocognitive disorders because some informants were not willing
or cognitively incapable to fill out the questionnaire. Group differences in age, sex, and education were analyzed using Tukey post hoc tests. Dunnett-Hsu post hoc tests were used to compare mean least-square
scores on the BHA, BHS, and MoCA between each patient group and the control group.
*Group differs from healthy control group at p<.05.

GIANINA ET AL.5of8
z-scores, the BHS sum score, and the MoCA sum score in our logistic
regression models.
Because not all informants were cognitively able or willing to fill out
the BHS, the total rate of missing values across the sample of patients
(mild neurocognitive disorder, n=6; major neurocognitive disorder,
n=6) and healthy controls (n=3) was 13%. There were no missing data
for any of the other variables. To include all participants in our statisti-
cal analyses, we applied multiple imputation analysis in SAS (PROC MI)
to estimate the missing values, using the fully conditional specification
method and 13 imputation cycles (White et al., 2011).
3RESULTS
3.1 Demographic and clinical characteristics
We attempted to match the two patient groups and the healthy control
group as closely as possible and selected the healthy control partici-
pants based on each patient’s demographics. In line with this approach,
the three subgroups did not statistically differ with regard to age, sex,
or education (see Table 1). In addition, and consistent with our expec-
tations, the two patient groups had significantly lower scores on the
Favorites, Match, and Animal Fluency tasks of the BHA, as well as on
the MoCA total score (Table 1). The threshold score of the Line Orien-
tation task was significantly higher, that is, worse (p<.05), in patients
with major neurocognitive disorder (M ±SD: 7.86 ±4.82) compared
to healthy controls (5.42 ±2.59). By contrast, the average threshold
score of patients with mild neurocognitive disorder (6.92 ±4.63) did
not significantly differ from the healthy control group (5.42 ±2.59).
3.2 Characteristics of the tablet-based
assessment for differential diagnosis
To determine how well the German version of the tablet-based assess-
ment can distinguish between patients and controls, we performed
logistic regression analyses and calculated area under the ROC curves
(AUCs) for the complete instrument (BHA +BHS), the cognitive BHA
alone, and the MoCA total score. For both the distinction of (1)
patients with mild neurocognitive disorder versus healthy controls and
(2) patients with major neurocognitive disorder versus healthy con-
trols, the complete instrument (BHA +BHS) had the highest AUC
when compared with the cognitive BHA alone or the MoCA alone
(Table 2and Figure 1a,b). As shown in Table 2, the AUCs of the three
measures, which were all excellent, were comparable for differential
diagnosis of patients with major neurocognitive disorder and healthy
controls, ranging between 0.98 and 0.99. While the AUCs distinguish-
ing patients with mild neurocognitive disorder from healthy controls
were also excellent for the complete instrument (0.95), the AUCfor the
MoCA was good (0.89).
In the second step, we investigated the impact of amyloid status on
the accuracy of the three measures to correctly distinguish patients
from controls. Thus, we examined the AUCs of the tablet-based assess-
TAB LE 2 Area under the ROC curve (AUC) and sensitivity (SEN) for different measures and group comparisons.
Mild NCD/controls Major NCD/controls NCD amyloid+/controls NCD amyloid−/controls
AUC SEN AUC SEN AUC SEN AUC SEN
BHA +BHS 0.95 0.88 0.99 0.98 0.97 0.98 0.96 0.95
BHA 0.91 0.86 0.98 0.94 0.97 0.97 0.92 0.90
MoCA 0.89 0.75 0.98 0.98 0.95 0.93 0.90 0.75
Note: Sensitivity is provided at a specificity level of 85%.
Abbreviations: BHA, brain health assessment; BHS, brain health survey; MoCA, Montreal CognitiveAssessment; NCD, neurocognitive disorder.

6of8 GIANINA ET AL.
FIGURE 1 Area under the ROC curves (AUCs) of the complete instrument (BHA +BHS), the cognitive BHA alone, and the Montreal Cognitive
Assessment (MoCA) shown for different group comparisons: (a) patients with mild neurocognitive disorder (NCD) versus cognitively healthy
controls; (b) patients with major neurocognitive disorder versus healthy controls; (c) patients with positive amyloid (amyloid+) status versus
healthy controls; (d) patients with negative amyloid (amyloid−) status versus healthy controls. BHA, brain health assessment; BHS, brain health
survey.
ment and the MoCA for differentiating patients for whom amyloid
status was available (positive: n=40; negative: n=20) from controls
(n=50). The AUC of the complete instrument was excellentand high in
distinguishing patients with (0.97) and without (0.96) amyloid pathol-
ogy from the healthy control group (Table 2and Figure 1c,d). While the
MoCA showed similar,slightly lower values, it was more accurate at dif-
ferentiating patients with (0.95) than without (0.90) amyloid pathology
from controls.
4DISCUSSION
To improve early diagnosis of patients with progressive neurodegen-
erative disorders, efficient and accurate cognitive screens are needed
for PCP across the world (Borson et al., 2013). Two previous studies
have shown that the English and Spanish versions of the tablet-based
UCSF BHA/BHS are more accurate at detecting early symptoms of
patients with mild neurocognitive disorder than existing paper-and-
pencil-based tests like the MMSE and MoCA. In the present validation
study performed at three memory clinics in Switzerland, we confirm
these previous cross-cultural findings from other high- and middle-
income countries. We confirmed that the German versions of both the
tablet-based BHA/BHS and the MoCA accurately detected major neu-
rocognitive disorder; however, the complete instrument (BHA +BHS)
was more sensitive to (1) mild neurocognitive disorder and (2) neu-
rocognitive disorder due to non-AD pathology than the cognitive BHA
alone or the MoCA. This study suggests that using the standard high
German version of the BHA/BHS instrument in primary care practices
may result in a higher number of early and accurate diagnoses of typical
and atypical presentations of neurodegenerative diseases and of refer-
rals to dementia specialist centers. The usability of this new German
version of the tablet-based BHA/BHS is not limited to Switzerland, but
it can be more broadly used in any German-speaking country in Europe,
including Germany and Austria. Our findings are of high importance to
both urban and rural areas in these countries where PCP are involved
in both the diagnostic decision-making process and triage of patients
to specialists.
The tablet-based BHA/BHS was previously validated at the clini-
cal, neuroanatomical, and neuropathological level (Possin et al., 2018;
Tsoy et al., 2021). The face-to-face test includes automated scoring
and is easily used even by individuals with cognitive impairment and
limited computer experience. The informant-based BHS consists of
24 questions about the most typical behavioral and motor symptoms
seen in patients with frontotemporal lobar degeneration syndromes

GIANINA ET AL.7of8
(Rabinovici & Miller, 2010). Because of the excellent combined sen-
sitivity and specificity of the complete instrument (BHA +BHS) to
detect mild and major neurocognitive cognitive disorder regardless
of amyloid status, we recommend that, if possible, PCP use both the
BHA (10 min administration time with the patient) and the BHS (5 min
administration time for the caregiver) in clinical routine. Importantly,
both the combined instrument and the cognitive BHA alone had excel-
lent accuracy in distinguishing patients from controls, outperforming
the paper-and-pencil-based MoCA. The finding that even the BHA
alone accurately detects early neurocognitive disorders with different
underlying etiologies is practically relevant because informants cannot
always be included in the diagnostic process due to issues such as infor-
mant unavailability, diminished cognitive status, and unwillingness to
provide information about the patient.
At a specificity level of 85%, the sensitivity of the MoCA to detect
mild cognitive impairment was much higher in the Swiss (0.75) sam-
ple than the US (0.25) sample. The MoCA was originally developed for
the early detection of patients with AD and shows excellent sensitivity
and specificity to mild neurocognitive disorder due to underlying AD
pathology (Nasreddine et al., 2005). Thus, the discrepancy between the
two studies may at least partly be explained by the fact that the Swiss
sample consisted of a higher proportion of AD-related neurocognitive
disorders than the US sample.
5 LIMITATIONS AND FUTURE DIRECTIONS
The overarching goal of this multi-site study was to show the valid-
ity of the standard high German version of the tablet-based BHA and
BHS for the early diagnosis of neurocognitive disorders. Because the
English version of the tool has been thoroughly validated both neu-
roanatomically and neuropsychologically (Possin et al., 2018), the focus
of this study was to validate the instrument on the behavioral level.
Due to its brevity, automated scoring, and accuracy for differential
diagnosis of early neurodegenerative diseases and cognitively healthy
individuals, the German version of the tablet-based BHA/BHS provides
a suitable screening instrument for primary care providers in German-
speaking countries. However, the current study does not provide any
information about PCP’s perceptions of the usefulness of the instru-
ment or its impact on the diagnostic process in primary care settings.
In addition, there are several practice-level barriersaround scheduling
and expertise that may prevent physicians from evaluating cognition
in routine clinical care (Kaduszkiewicz et al., 2010; Koch et al., 2010;
Sabbagh et al., 2020), even in the presence of sensitive instruments
such as the BHA and BHS. Therefore, additional implementation work
must be done before PCP in Switzerland and other German-speaking
countries can effectively adopt the BHA/BHS instrument, which is a
worthwhile endeavor because of its excellent accuracy in detecting
early symptoms of neurodegenerative disorders. To directly imple-
ment the instrument in primary care practice, health systems must
provide guidance around the management of the electronic applica-
tion, protocols for patient data collection and storage, and provider
education around interpretation of results and follow-up recommen-
dations after cognitive evaluation. These steps would overcome many
current health system barriers to implementing efficient and accu-
rate cognitive testing in primary care settings, which in turn would
improve an early diagnosis of neurodegenerative disorders and ulti-
mately result in better care of affected patients and families. Finally,
future research is warranted to investigate longitudinal models of the
German TabCAT-BHA, including prediction of decline, long-term stabil-
ity, and change over time in individuals with early neurodegenerative
diseases.
AUTHOR CONTRIBUTIONS
G.T. and A.F. conceived the study and raised funding. G.T., L.S. and D.K.
performed cognitive tests and supported G.T. in the statistical analyses.
G.T., L.S., D.K., F.K., T.M., U.K., A.M. and A.F. recruited the patients and
collected the clinical data. P.C., K.P., K.R. developed the original tests
in english language. G.T. and A.F. wrote the manuscript and all authors
contributed to editing and revising the manuscript.
ACKNOWLEDGMENTS
We thank the patients and their relatives for participating in our
research. We also acknowledge Roman Bühlmann for his help with
the German translations of the BHA and BHS. This study was funded
by a research grant (number 20/33) of the research committee of the
Cantonal Hospital of St. Gallen.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
DATA AVAILABILITY STATEMENT
Anonymized data will be shared on request from any qualified investi-
gator for the purposes of replicating procedures and results.
ORCID
Toller Gianina https://orcid.org/0000-0002-0200-7949
PEER REVIEW
The peer review history for this article is available at https://publons.
com/publon/10.1002/brb3.3329
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How to cite this article: Gianina, T., Lorena, S., Dilaxy, K.,
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