Among non-English speaking (NES) immigrants, Korean immigrants are a rapidly growing ethnic group in the community at large and American nursing homes (Centers for Disease Control and Prevention, 2013). Psychological issues associated with Korean caregivers who choose nursing home placement for loved ones are well documented (Kong, Deatrick, & Evans, 2010); however, information about the unique challenges of Korean older adults who come to long-term care settings in the United States is less understood. The Korean older adult population could be considered a vulnerable one, given that Korean older adults speak a different language and have different cultural values than the majority of residents and staff in American nursing homes. Two thirds of Korean American older adults are unable to speak and understand English (Koh & Bell, 1987), whereas the majority of facility staffs in the United States do not speak Korean. Furthermore, few American nursing homes receiving Korean older adults are knowledgeable about Korean culture. Among individuals with dementia in nursing homes, those who are NES may be particularly vulnerable to psychological issues and health declines (Mattern & Camp, 1998), and further complicating communication issues, Korean adults who had learned English as a second language may lose command of English as their dementia progresses (Forbat, 2003).
Among American English-speaking older adults residing in nursing homes, the prevalence of cognitive impairment is high (Mansbach, MacDougall, Clark, & Mace, 2014). It is estimated that more than one half of this population has significant cognitive deficits (Magaziner et al., 2000). Empirical evidence of actual prevalence rates of cognitive impairment among Korean adults in American nursing homes is less clear, but it is likely at least as high as other nursing home populations. Studies indicate that older Korean American adults are less likely to seek formal dementia care and are more likely to delay nursing home admissions than American-born older adults (Chee & Levkoff, 2001; Watari & Gatz, 2004). Consequently, they may be older, frailer, and more cognitively impaired than other residents.
To better understand cognitive functioning in Korean American nursing home residents, the authors of the current article developed a Korean version of the Brief Cognitive Assessment Tool—Short Form (BCAT-SF; Mansbach & MacDougall, 2012). The BCAT-SF was selected because it can be administered in 5 minutes or less, was developed for long-term care settings, does not have an education bias, has strong psychometric properties, and is frequently used in American nursing homes. The education bias issue is particularly important, as previous researchers have reported that a majority of Korean older adults have less than a seventh grade education (Lee et al., 2002). The authors’ primary aims for the current pilot project were to investigate the psychometric properties of a Korean version of the Brief Cognitive Assessment Tool—Short Form (BCAT-SF-K) in a Korean nursing home sample and use the BCAT-SF-K to describe cognitive functioning for these residents. In Step I of the project, the authors established normative values for the BCAT-SF-K based on a Korean American community-dwelling older adult sample. In Step II, they established construct validity of the BCAT-SF-K for Korean American nursing home residents. Key demographic and cognitive features of the sample are described.
Community Sample: Step I. The authors prospectively recruited community-dwelling participants over a 6-month period. The Korean American Community Association approved the current study, reviewed the procedures, and helped recruit participants. All participants or surrogate decision makers completed individual informed consent agreements. Using a Korean version of the Mini-Mental State Examination (MMSE-KC), which was adapted from the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD-K; Lee et al., 2002), a conservative cutoff score of >26 (of a maximum 30 points) was used for identifying cognitively normal participants. Forty-eight participants were recruited, and 34 were categorized as having normal cognition. Participants who showed evidence of cognitive impairment (i.e., MMSE-KC scores <27) were excluded to establish normative values for the BCAT-SF-K. In addition to having an MMSE-KC score of 27 or higher, inclusion criteria for the normative group included a complete BCAT-SF-K, fluency in Korean as the primary language, and age >55. Participants ranged in age from 57 to 99, with a mean age of 78.62 years (SD = 9.46 years). All participants were Korean American, and 65% were female. Thirty-eight percent of participants had less than an eighth grade education, 41% had a high school education, and 21% had some college education.
Nursing Home Sample: Step II. Thirty-four individuals residing in a Maryland skilled nursing facility were prospectively recruited over a 6-month period. All patients resided on a dually certified Korean unit and were attended by Korean-speaking staff (e.g., nursing, secretarial, recreation, dietary staff). Twenty-six of those nursing home residents met inclusion criteria for data analysis, which required a complete BCAT-SF-K, fluency in Korean as the primary language, and age >55. Participants ranged in age from 65 to 99, with a mean age of 84.58 years (SD = 7.72 years). As shown in Table 1, all participants were Korean American, 85% of participants were female, and 65% were widowed. Thirty-one percent of participants had at least 12 years of education, 46% had 8 years or less, and 23% had no formal education. Forty-six percent of participants stated their previous occupation as homemaker.
Demographics of the Community (Step I) and Nursing Home (Step II) Samples
Step I. All participants reviewed and signed an informed consent document before completing a short battery of individually administered cognitive tests, including the MMSE-KC and BCAT-SF-K. One licensed psychologist and several Korean-speaking research assistants, trained in administering the MMSE-KC and BCAT-SF-K, collected all data for Step I of the study.
Step II. All procedures were approved by the nursing home’s medical ethics committee. Participants or surrogate decision makers reviewed and signed an informed consent document before completing a short battery of several individually administered cognitive tests and a depression scale. Three trained mental health technicians administered the MMSE-KC and BCAT-SF-K. In addition, four trained social workers independently administered the Brief Interview for Mental Status (BIMS; Chodosh et al., 2008) and Patient Health Questionnaire-9 (PHQ-9; Saliba et al., 2012). Test order was determined by assigning participants to one of two protocols. In protocol A, the order of testing was as follows: BCAT-SF-K and MMSE-KC, then BIMS and PHQ-9. In protocol B, the order of testing was as follows: BIMS and PHQ-9, then BCAT-SF-K and MMSEKC. Those who administered the BIMS and PHQ-9 had no knowledge of the test results of the BCAT-SF-K and MMSEK. Those who administered the BCAT-SF-K and MMSE-K did not have knowledge of participants’ BIMS and PHQ-9 scores.
All statistical analyses were performed using SPSS version 22.0. Descriptive statistics were used to report participant demographics and assessment tool scores. Internal consistency reliability was estimated using Cronbach’s alpha coefficient. Convergent and divergent validity was addressed with Spearman’s correlation coefficients. In Step I, the authors defined normal cognition for the BCAT-SF-K based on the MMSE-KC-reported normative reference values (Lee et al., 2002). Participants who scored in the normal cognition range based on MMSE-KC scores were selected. The authors then calculated the BCAT-SF-K cutoffs based on standard deviations below the mean value for the cognitively normal group. Normal cognition was defined by mean +1 SD for the normal group, mild impairment was defined by scores between mean −1 SD and −2 SD, and severe impairment was defined by scores below mean −2 SD. This methodological approach to establish cutoff scores is generally consistent with other Korean adaptations of the MMSE (Han et al., 2008; Kim et al., 2011). In Step II, the authors applied the BCAT-SF-K cutoffs to the sample to describe cognitive features of the nursing home sample.
BCAT-SF-K. The BCAT-SF-K is a Korean adaptation of the BCAT-SF (Mansbach & MacDougall, 2012). The BCAT-SF is an abridged version of the full BCAT (Mansbach, MacDougall, & Rosenzwieg, 2012) and was designed for instances when time for cognitive screening is constrained and when patients cannot tolerate a longer test. The BCAT-SF can be administered in less than 5 minutes, with scores ranging from 0 to 21. Higher scores indicate stronger cognitive functioning, and lower scores indicate weaker cognitive functioning. To maintain content validity, Mansbach & MacDougall (2012) selected six items from the original BCAT that represent the cognitive domains of contextual memory, executive functioning, and attentional capacity. A total of 104 older adults from assisted-living facilities (87.5%, n = 91) and the “independent” section within continuing care retirement communities (12.5%, n = 13) participated in the development and validation of the BCAT-SF. Psychometric analyses yielded an internal consistency reliability of 0.86 (Cronbach’s alpha based on standardized items), a test–retest reliability of r = 0.98, and preliminary evidence of the construct validity of BCAT score inferences through convergent, discriminant, and predictive validity analyses. Using a cutoff score of ≤15, the BCAT-SF differentiated between mild cognitive impairment and dementia with a sensitivity of 0.90 and a specificity of 0.81 (area under the curve [AUC] = 0.93) (Mansbach & MacDougall, 2012). Similar to the BCAT, the BCAT-SF has been shown to predict instrumental activities of daily living (Mansbach & MacDougall, 2012).
The BCAT-SF-K was developed over a 5-week period. The authors’ primary concern was to ensure that the instrument was culturally sensitive to the Korean American older adult population while maintaining the integrity of the original BCAT-SF. Three Korean-speaking nursing professionals individually translated the questions from the original BCAT-SF and subsequently reconciled differences in their translations to create a final version. Two items were modified to improve translation. In story recall, the names of the characters were subsequently changed to be consistent with common Korean names. In addition, the Korean translation of the English word justice was changed to be more culturally sensitive. Finally, the BCAT-SF-K underwent three versions to format the Korean language characters in a manner that optimized test administration. Each version was modified based on feedback from Korean-speaking test administrators. To ensure the cultural sensitivity of the translated items, a translator provided backward translation feedback.
MMSE-KC. The MMSE (Folstein, Folstein, & McHugh, 1975) has undoubtedly been the most frequently used screening measure for dementia, and it has been translated into several languages since its introduction approximately 40 years ago. Lee et al. (2002) translated the test words of the original MMSE, as part of the CERAD-K neuropsychological battery, into equivalent Korean words to create the MMSE-KC. The MMSE-KC has 19 items, and scores range from 0 to 30. Higher scores indicate stronger cognitive functioning, and lower scores indicate weaker cognitive functioning. Psychometric analyses from the Lee et al. (2002) development study (N = 652) yielded an internal reliability coefficient of 0.92 (Cronbach’s alpha based on standardized items). Further evidence of the construct validity of MMSE-KC scores were addressed through test–retest reliability (r = 0.58) and convergent, discriminant, and predictive validity analyses. In the Lee et al. (2002) control group (n = 186), patients without a dementia diagnosis scored significantly higher on the MMSE-KC (mean = 28, SD = 1.7) than those with dementia (n = 106; mean = 16.5, SD = 6.5) and Alzheimer’s disease (n = 78; mean = 16.4, SD = 6.9). The MMSE-KC had an internal consistency reliability of 0.87 (Cronbach’s alpha based on standardized items) in the total sample of the current study.
BIMS. The 7-item BIMS (Chodosh et al., 2008) is an integral part of the Minimum Data Set 3.0 (MDS 3.0) mandated for American nursing homes (Saliba et al., 2012). To the best of the authors’ knowledge, no published Korean translation exists that has been normed on a Korean American nursing home sample. The BIMS focuses on two domains of cognitive function (i.e., memory and orientation), with scores ranging from 0 to 15. Higher scores indicate stronger cognitive functioning, and lower scores indicate weaker cognitive functioning. The development study (N = 374) established interrater reliability between research assistant and facility nurse administrations of the BIMS within 72 hours of each other (r = 0.72) and found a correlation (r = 0.79, p < 0.01) with the Modified MMSE (3MS; Teng & Chui, 1987). Of the 90% of participants (n = 3,258) who completed a BIMS in the national MDS 3.0 evaluation study, Saliba et al. (2012) noted that a score of 7 had a sensitivity of 0.83 and specificity of 0.92 (AUC = 0.93) for identifying any form of impairment based on the 100-point 3MS (score ≤78).
PHQ-9. The PHQ-9 is the self-administered 9-item depression scale of the Spitzer, Kroenke, and Williams (1999) Patient Health Questionnaire. The PHQ-9 is based directly on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) diagnostic criteria for major depressive disorder, with scores ranging from 0 to 27. Assessing symptoms and functional impairment, higher scores indicate a tentative depression diagnosis as well as a level of severity of depression. The initial development study of 6,000 patients in primary care and obstetrics–gynecology clinics demonstrated internal consistency reliability (Cronbach’s alpha = 0.89) and alternate forms reliability between the self-administered and a telephonically administered PHQ-9 within 48 hours (r = 0.84; Kroenke, Spitzer, & Williams, 2001). The PHQ-9, which was also completed by 86% of the 3,258 MDS 3.0 participants (Saliba et al., 2012), established criterion validity.
The distribution of MMSE-KC (range = 6 to 30) and BCAT-SF-K (range = 1 to 21) raw scores in the total sample was positively skewed. Median MMSE-KC and BCATSF-K scores were not significantly different for education, sex, or marital status. However, the MMSE-KC (rs = −0.58, p < 0.001) and BCAT-SF-K (rs = −0.61, p < 0.001) scores were significantly correlated with age. Individual items on the BCAT-SF-K exhibited an acceptable ability to discriminate between high and low total BCAT-SF-K scores (Bearden & Netemeyer, 1999), with corrected item-total correlations ranging from 0.67 to 0.87.
In the total sample, the internal consistency reliability of BCAT-SF-K scores (as estimated by Cronbach’s alpha based on standardized items) was 0.89. This coefficient is well within the acceptable range for tests that will be used for clinical decision making (Nunnally & Bernstein, 1994).
Table 2 presents descriptive statistics for all validity measures used in the current study. Construct validity was supported by significant correlation of the BCAT-SF-K scores with two other measures of cognitive functioning, the MMSE-KC (rs = 0.75, p < 0.001) and BIMS (rs = 0.66, p < 0.001). Discriminant validity was supported by nonsignificant correlations between the BCAT-SF-K and PHQ-9, a measure of depressed mood (rs = −0.03, p = 0.90). When classifying participants using the PHQ-9, BCAT-SF-K mean scores were not significantly different for individuals with depression (PHQ-9 scores ≥5; mean = 10.57, SD = 5.51) compared to those without depression (mean = 9.83, SD = 5.06; t = −0.31; p = 0.76). Finally, participants in the nursing home sample scored significantly lower on the BCAT-SF-K (mean = 9.69, SD = 5.48) than participants in the community sample (mean = 19.68, SD = 1.41; t = 10.21; p < 0.001; Cohen’s d = 2.50).
Descriptive Statistics for Validity Measures
Average MMSE-KC scores (mean = 28.7, SD = 1.33) for participants in Step I were generally consistent with the scores for the normal cognition control subgroup reported in the Lee et al. (2002) development study. When identifying community-dwelling participants with normal cognition (MMSE-KC scores ≥27), the mean BCAT-SF-K score was 19.68 (SD = 1.41). Based on mean −1 SD, −1 SD to −2 SD, and −2 SD criteria, the authors calculated the BCAT-SF-K cutoffs as follows: normal cognition (18 to 21), mild impairment (16 to 17), and severe impairment (≤15).
In Step II, average MMSE-KC scores (mean = 16, SD = 4.91) for participants in the nursing home sample were also consistent with the scores for the subgroup with dementia reported in the Lee et al. (2002) development study. Using the BCAT-SF-K cutoffs established in Step I to classify participants in the nursing home sample, 84.6% had severe cognitive impairment, 7.7% had mild impairment, and 7.7% had normal cognition.
The BCAT-SF-K demonstrated acceptable reliability and strong construct validity. Based on a small normal control sample of community-dwelling Korean American older adults, three cognitive functioning levels were established. The authors suggest that BCAT-SF-K score ranges of 18 to 21, 16 to 17, and ≤15 indicate normal cognition, mild impairment, and severe impairment, respectively. Many useful comparisons can be made between the current study’s findings and those from other studies, as well as between the two study samples. The suggested score range for severe cognitive impairment in the present sample replicated the suggested range for dementia in the original BCAT-SF study, as the authors reported a cutoff score for dementia of <16 (Mansbach & MacDougall, 2012). The current study’s community sample obtained MMSE-KC scores that were similar to those reported by Lee et al. (2002) from a larger sample, providing further support for the accuracy of the normative values reported in this study.
In the nursing home sample, the majority of participants were female, approximately one half had 8 years of education or less, and approximately one half reported their occupation as homemaker. Because so little data are available, it is challenging to compare these demographics with previous Korean American nursing homes studies. However, useful comparisons can be made with general nursing home demographics. Of particular importance is that 85% of the nursing home participants could be classified as having severe cognitive impairment. This percentage is even higher than what is reported in a majority of nursing home prevalence studies (Centers for Medicare & Medicaid Services [CMS], 2013). One possible explanation for this finding is that the average age of the sample is 85, which is significantly older than the average nursing home resident at large (CMS, 2013). The high prevalence of cognitive impairment is also consistent with the observation that Korean American families tend to delay nursing home placement until age and impairment exceed community and familial support resources (Chee & Levkoff, 2001); waiting as long as possible to admit a loved one to long-term care is consistent with the traditional Confucian values. Further support of this delay is found when comparing the community-dwelling and nursing home samples: in the former sample, participants were younger and cognitively healthier than participants from the nursing home sample.
Data regarding the nursing home sample are instructive from a care perspective. Based on the current study’s findings, nursing home providers should recognize that their Korean American residents may have special needs that further complicate existing language and culture differences, stemming from significant cognitive deficits. From a resident-centered perspective, inclusion of family and other surrogate decision makers may be more critical to care than with other residents who may be more cognitively intact and better able to communicate their wants and needs.
Important limitations to the current findings exist. First, the samples are relatively small. Therefore, the findings should be regarded as preliminary. In addition, the authors used a reliable Korean cognitive screening measure, originally normed as part of the development of a larger Korean version of the CERAD. However, they did not use a “gold standard” for making cognitive diagnoses, unlike in the original BCAT-SF study where a comprehensive neuropsychological battery was independently used to identify cognitive levels (Mansbach & MacDougall, 2012). Future research that attempts to cross-validate these findings and uses broader assessment instruments would be a valuable contribution. Demographic differences between the two samples, particularly age, may also limit the generalizability of normative values. Finally, although the measures were counterbalanced in the nursing home sample, they were not counterbalanced in the community sample.
Based on the current two-step preliminary study, the BCAT-SF-K appears to be a reliable cognitive screening measure for Korean American older adults. Furthermore, based on the nursing home sample, Korean American nursing home residents tend to be older and more cognitively impaired than community-dwelling Korean American older adults, as well as the general American nursing home population. An important next step is to replicate these findings using larger and more diverse samples.
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Demographics of the Community (Step I) and Nursing Home (Step II) Samples
|Characteristic||Step I (n = 34) (n [%])||Step II (n = 26) (n [%])|
| Female||22 (64.7)||22 (84.6)|
| Male||12 (35.3)||4 (15.4)|
| Asian||34 (100)||26 (100)|
| Married||—||9 (34.6)|
| Widowed||—||17 (65.4)|
|Education (years completed)|
| 0||0 (0)||6 (23.1)|
| <12||11 (32.4)||12 (46.2)|
| 12||12 (35.3)||1 (3.8)|
| >12||6 (17.6)||7 (26.9)|
|Missing||5 (14.7)||0 (0)|
Descriptive Statistics for Validity Measures
|Community (n = 34)||BCAT-SF-K||20||19.68 (1.41)||16 to 21|
|MMSE-KC||29||28.74 (1.33)||27 to 30|
|Nursing Home (n = 26)||BCAT-SF-K||9.5||9.69 (5.48)||6 to 25|
|MMSE-KCa||16||16 (4.91)||6 to 25|
|BIMS||11||10.5 (3.57)||3 to 15|
|PHQ-9b||3||3.64 (3.7)||0 to 11|