The Turkish validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery

Ozakbas et al. BMC Neurology (2017) 17:208 DOI 10.1186/s12883-017-0993-0 RESEARCH ARTICLE Open Access The Turkish validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery Serkan Ozakbas1, Pinar Yigit1, Bilge Piri Cinar2*, Hatice Limoncu1, Turhan Kahraman3 and Görkem Kösehasanoğulları4 Abstract Background: Cognitive impairment may be seen in as many as 43–70% of patients with multiple sclerosis (MS) and may be observed in all MS subtypes. The Brief International Cognitive Assessment in Multiple Sclerosis (BICAMS) battery may be used to evaluate cognition status. The purpose of the current study is to validate the BICAMS battery in Turkish. Methods: Patients with MS attending our clinic between September 2014 and April 2015 were invited to participate. Healthy control participants were matched in terms of age, gender and years of education. Results: One hundred seventy-three MS patients and 153 healthy control participants were enrolled in the study. MS patients performed significantly worse in all trials than the members of the healthy control group. In addition, cognitive dysfunction was identified in 78 of the 173 (45.1%) patients. In the MS with cognitive impairment group, 64 out of 151 (42.4%) subjects were RRMS patients, 12 out of 18 (66.7%) were secondary progressive MS patients, and 2 out of 4 (50%) were primer progressive MS patients. Conclusions: The BICAMS has been proposed for assessing cognitive impairment in MS patients. This study shows that the battery is suitable for use in Turkey. Keywords: Multiple sclerosis, BICAMS battery, Cognitive impairment Background Cognitive impairment is common in multiple sclerosis (MS), and approximately half of patients with MS present with cognitive impairment that adversely impacts on aspects of both patients’ and caregivers’ everyday lives [1, 2]. It is demonstrable in all disease stages and subtypes, in up to 40% of newly diagnosed individuals with clinically isolated syndrome and relapsing remitting MS (RRMS) [3] and in up to 60% of those with secondary progressive MS (SPMS) [4]. It can have a significant impact on quality of life and can influence employment status, physical independence, communications, treatment adherence and even rehabilitation benefit [2]. The assessment of MS-related cognitive decline has received increasing attention in recent * Correspondence: 2 Department of Neurology, Samsun Training and Researce Hospital, Samsun, Turkey Full list of author information is available at the end of the article decades. Many different neuropsychological batteries have been proposed. However, the Brief Repeatable Battery of Neuropsychological tests (BRB-N) [5] and the Minimal Assessment of Cognitive Function in MS (MACFIMS) [4, 6] are the most popular tools. While both batteries are known to be highly specific for the evaluation of cognitive impairment in MS patients, their implementation in everyday clinical practice remains limited due to their high time demands (at least 45 min are required for BRB-N and 90 min for MACFIMS) and the need for surveillance and interpretation by specialist neuropsychologists [4–7]. Various neuropsychological batteries have been proposed for the assessment of cognitive impairment in MS as the interest in this area has increased over recent years. The Brief International Cognitive Assessment in Multiple Sclerosis (BICAMS) was proposed by an expert panel as a tool for brief cognitive monitoring of MS patients in clinical settings in 2012 [8]. It can be administered by healthcare © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ozakbas et al. BMC Neurology (2017) 17:208 professionals without any formal neuropsychological training to identify early or subtle cognitive impairment. The BICAMS battery is a fast, reliable, sensitive and specific tool that has been validated and applied in many countries [9–14]. The primary objective of our study was the crosscultural validation of the BICAMS battery to Turkish. The secondary objective was to measure the impact of cognitive impairment on patients’ quality of life and the effect of fatigue on patients’ cognitive state by assessing correlations between BICAMS performance and the Modified Fatigue Impact Scale (MFIS) and the Multiple Sclerosis International Quality of Life (MUSIQoL) questionnaire. Methods Patients Patients with a diagnosis of MS according to the 2010 revised McDonald criteria [15] attending our clinic between September, 2014, and April, 2015, were invited to participate. Patients were recruited cross-sectionally, and no preselection was applied for cognitive impairment. The inclusion criteria were age over 18 years, the ability to give informed consent, neurological stability with no evidence of relapse, being steroid and/or plasmapheresis-free for at least 4 weeks preceding enrollment, and proficiency in the Turkish language. Patients were excluded if they had a current or previous neurological disorder other than MS, a current psychiatric disorder unrelated to that diagnosis, a coexistent medical condition that might influence cognition, a previous history of developmental disorder unrelated to MS, a history of learning disability, any vision or hearing problems that might influence performance on the tests, or a current or past history of alcohol or drug abuse. Control participants were recruited from unaffected relatives or friends of MS patients or from other individuals attending the neurology outpatient clinic for other reasons, such as migraine or vertigo. All relatives were matched in terms of age, gender and years of education. All patients and all healthy control subjects provided verbal informed consent to participation in the study. Approval for the research project was granted by the Ethics Committee of Dokuz Eylul University of Izmir. Study instruments and procedures The methodology employed followed the recommendations for BICAMS national validation (step 1; standardization and translation of test stimuli, step 2; standardization and translation of test instructions, step 3; normalization, step 4; test-retest reliability, step 5; criterion-related validity) [16]. Age, sex, handedness, years of education, occupation and employment status were recorded for all participants. In the MS group, disease subtype, expanded disability status scale (EDSS) [17] and disease duration from onset of symptoms were also noted (...truncated)