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

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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 1. Background 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. Methods 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. Results 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 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 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. 4. Discussion 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. 5. Conclusions 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. Abbreviations BOCA Boston Cognitive Assessment ICC Intra-group correlation coefficient MMSE Mini-Mental State Examination MoCA Montreal Cognitive Assessment TICS Telephone Interview for Cognitive Status Declarations 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. References Jia J, Wang F, Wei C, Zhou A, Jia X, Li F, et al. The prevalence of dementia in urban and rural areas of China. 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Cognitive reserve in ageing and Alzheimer's disease. Lancet Neurol. 2012;11(11):1006–12. Stern Y. Cognitive reserve. Neuropsychologia. 2009;47(10):2015–28. Stern Y. What is cognitive reserve? Theory and research application of the reserve concept. J Int Neuropsychol Soc. 2002;8(3):448–60. Harrison SL, Sajjad A, Bramer WM, Ikram MA, Tiemeier H, Stephan BC. Exploring strategies to operationalize cognitive reserve: A systematic review of reviews. J Clin Exp Neuropsychol. 2015;37(3):253–64. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4821369","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335161768,"identity":"e3481fab-d91b-47a0-88df-a2dbfbb61ea3","order_by":0,"name":"Jiahui Ding","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jiahui","middleName":"","lastName":"Ding","suffix":""},{"id":335161769,"identity":"b7d0553f-87dc-4030-a9f2-d9e6b7bae7a8","order_by":1,"name":"Xiaoxia Gao","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxia","middleName":"","lastName":"Gao","suffix":""},{"id":335161770,"identity":"251b0314-07d7-4042-94d4-4425f7b0d6c1","order_by":2,"name":"Ying Tang","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Tang","suffix":""},{"id":335161771,"identity":"6841c12e-5a0d-455e-bdd8-b7b8e7cbbac0","order_by":3,"name":"Yehuan Wu","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yehuan","middleName":"","lastName":"Wu","suffix":""},{"id":335161772,"identity":"3f82a1c9-4083-4df8-b0ab-240497e497b4","order_by":4,"name":"Xiaofang Yuan","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Xiaofang","middleName":"","lastName":"Yuan","suffix":""},{"id":335161773,"identity":"a7fb9846-331c-4945-ad2f-abc132ffcccd","order_by":5,"name":"Jianan Zhang","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jianan","middleName":"","lastName":"Zhang","suffix":""},{"id":335161774,"identity":"bf8d4b84-c516-4ebf-89d5-b4935f1f0dcf","order_by":6,"name":"Yue Shi","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Shi","suffix":""},{"id":335161775,"identity":"3c58602a-2572-49e4-a128-9f5f5b048831","order_by":7,"name":"Ya Wang","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ya","middleName":"","lastName":"Wang","suffix":""},{"id":335161776,"identity":"dcbb3733-b91d-4a9c-9f9c-aa5a635ddc95","order_by":8,"name":"Jing Guo","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Guo","suffix":""},{"id":335161777,"identity":"a8eff17d-b7c9-4893-b6d0-c0d65b22a6ed","order_by":9,"name":"Xiao Fei","email":"","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Fei","suffix":""},{"id":335161778,"identity":"1e85b8f1-793b-42c1-8ded-5d2a5c3c18a3","order_by":10,"name":"Yi Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBAC+xlgSoLBgIGx8fHfPzYMfMwEtDAitDA3G/A2pDGwEamFAaiFvU2Ct+EwAxshhzFLNz97+LXNwt6cvbFNQnLHeXk2dh4z6QIGOzndBuxa2GSOmRvLtkkwW/YcbLYwPHPbsI0ZqGUGQ7Kx2QHsWngkEsykJdsk2AxuJDbeSGC7zQjWwsNwIHEbDi0SEunfQFp4DO4/bJA4wHbOnqAWA4kcM8mPbRISBjcYmyQb2w4kEqOlTJrhnISBwZnEZmOGM8nJbcxsxdY8Brj9Yj8jfZvkj7I6e4Pjxx8+Zqiws+3nP7zxNk+FnRwuLSDAzIsaFxwGoGjCCxh//EHhsz/Ar34UjIJRMApGGgAAMCZUG3KXWuYAAAAASUVORK5CYII=","orcid":"","institution":"The Third Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Yi","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-07-29 10:53:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4821369/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4821369/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72585028,"identity":"fd0376c1-fcb8-468e-9178-2e9691254855","added_by":"auto","created_at":"2024-12-30 06:08:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":658278,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4821369/v1/ee5e2e58-dced-4e49-9bdc-212985491e3b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A preliminary study on the use of the Boston Cognitive Assessment to assess cognitive function in a Chinese population","fulltext":[{"header":"1. Background","content":"\u003cp\u003eChina has the largest population in the world that is currently facing a significant aging problem. The seventh population census showed that more than 190\u0026nbsp;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\u0026thinsp;\u0026gt;\u0026thinsp;65 years is 5.14% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], while the prevalence of mild cognitive impairment is 20.8% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Cognitive impairment is becoming a serious public health problem in China, posing a significant socioeconomic burden [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. 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 [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently the most widely used cognitive screening scales include the Mini-Mental State Examination (MMSE) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and Montreal Cognitive Assessment (MoCA) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, a self-managing cognitive screening tool needs to be developed for effective and reliable longitudinal monitoring of overall cognitive status.\u003c/p\u003e \u003cp\u003eThe 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. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] 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\u0026ndash;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. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] 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\u0026rsquo;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.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Participants\u003c/h2\u003e \u003cp\u003eTo 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.\u003c/p\u003e \u003cp\u003eInclusion criteria: (1) Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years old; (2) in good health, with no previous central nervous system conditions, such as stroke, cerebral trauma, Parkinson\u0026rsquo;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.\u003c/p\u003e \u003cp\u003eExclusion 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.\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;39 years, 29 participants aged 40\u0026ndash;59 years, and 17 participants aged 60\u0026ndash;79 years. The range of years of schooling was 3\u0026ndash;16 years, and the participants were grouped according to length of schooling: 10 participants\u0026thinsp;\u0026le;\u0026thinsp;6 years, 17 participants from 7 to 9 years, 16 cases from 10 to 12 years, and 68 cases\u0026thinsp;\u0026ge;\u0026thinsp;13 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral data of study participants (n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProject\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConstituent ratio (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYears of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Evaluation methods\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1. Assessment tools\u003c/h2\u003e \u003cp\u003e(1) MMSE: Developed by Folstein et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], 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 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]: illiteracy\u0026thinsp;\u0026le;\u0026thinsp;19 points; primary school\u0026thinsp;\u0026le;\u0026thinsp;22 points; and secondary school or above \u0026le;\u0026thinsp;26 points.\u003c/p\u003e \u003cp\u003e(2) BOCA: Designed by Professor Andrey Vyshedskiy of Boston University and others [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2. Assessment process\u003c/h2\u003e \u003cp\u003eFirst, offline evaluation with the MMSE scale was conducted, and the online evaluation using the BOCA scale was performed after 24\u0026ndash;48 h. 1 month after completing the first BOCA scale evaluation, a second online re-evaluation of the BOCA scale was conducted.\u003c/p\u003e \u003cp\u003eThe 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\u0026rsquo;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.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eSPSS 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\u0026rsquo;s test was used to analyze the correlations between age, length of education and BOCA scores. The Cronbach\u0026rsquo;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\u0026ndash;retest reliability. The correlation analysis of each score and the total score was used to assess the content validity, while the Spearman\u0026rsquo;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.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1. MMSE and BOCA scores\u003c/h2\u003e \u003cp\u003eThe median (upper quartile\u0026ndash;lower quartile) of MMSE scores for the 111 healthy participants was 30 (29\u0026ndash;30) points, and the median (upper quartile\u0026ndash;lower quartile) of BOCA scores was 28 (25\u0026ndash;29) points.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.2. Comparison of MMSE and BOCA scores between different groups, and the correlations between demographic characteristics and scores\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe MMSE and BOCA scores of the different age groups differed significantly (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The pairwise comparison revealed that the MMSE and BOCA scores differed significantly between the 18\u0026ndash;39 and 40\u0026ndash;59 years old groups, as well as between the 18\u0026ndash;39 and 60\u0026ndash;79 years old groups. No significant difference was found between the 40\u0026ndash;59 and 60\u0026ndash;79 years old groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMMSE and BOCA scores of groups according to age bracket\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e18\u0026ndash;39 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e40\u0026ndash;59 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e60\u0026ndash;79 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eInter-group variance (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u0026ndash;39 years and vs. 40\u0026ndash;59 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u0026ndash;39 years vs. 60\u0026ndash;79 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u0026ndash;59 years vs. 60\u0026ndash;79 years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(30\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(28\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(27\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOCA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(27.5\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(24\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(22\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.\u003c/p\u003e \u003cp\u003eThe MMSE and BOCA scores differed significantly among the groups based on length of education (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The comparison showed that MMSE and BOCA scores differed significantly among the different length of education groups, particularly between \u0026ge;\u0026thinsp;13 and \u0026le;\u0026thinsp;6 years, \u0026ge;\u0026thinsp;13 and 7\u0026ndash;9 years, and \u0026ge;\u0026thinsp;13 and 10\u0026ndash;12 years. No significant differences were observed among \u0026le;\u0026thinsp;6 years, 7\u0026ndash;9 years and 10\u0026ndash;12 years (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMMSE and BOCA scores of groups based on length of education\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7\u0026ndash;9 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10\u0026ndash;12 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;13 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c11\" namest=\"c6\"\u003e \u003cp\u003eInter-group variance (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6 years vs 7\u0026ndash;9 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6 years vs. 10\u0026ndash;12 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6 years vs. \u0026ge;13 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u0026ndash;9 years vs. 10\u0026ndash;12 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u0026ndash;9 years vs. \u0026ge;13 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10\u0026ndash;12 years vs. \u0026ge;13 years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28(25.5\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(27\u0026thinsp;\u0026minus;\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.5(28\u0026thinsp;\u0026minus;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30(30\u0026thinsp;\u0026minus;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOCA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(19.25\u0026thinsp;\u0026minus;\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(21\u0026thinsp;\u0026minus;\u0026thinsp;26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27(23.25\u0026thinsp;\u0026minus;\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29(28\u0026thinsp;\u0026minus;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.\u003c/p\u003e \u003cp\u003eA moderate negative correlation was found between age and both total MMSE (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.605, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and BOCA scores (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.676, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The length of schooling was moderately positively correlated with both total MMSE (r\u0026thinsp;=\u0026thinsp;0.641, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and BOCA (r\u0026thinsp;=\u0026thinsp;0.689, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Reliability analysis\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Internal consistency\u003c/h2\u003e \u003cp\u003eThe overall Cronbach\u0026rsquo;s α coefficient of the BOCA scale was 0.774, indicating high internal consistency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Test\u0026ndash;retest reliability\u003c/h2\u003e \u003cp\u003eThe intra-group correlation coefficient of the overall test\u0026ndash;retest reliability was 0.796. The test\u0026ndash;retest reliability of each item (except for clock test/execution function and orientation) was good, and the ICC value \u0026gt; 0.5, confirming the good test\u0026ndash;retest reliability of the scale (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eICC values of subscales scores and total scores for the BOCA scale on the first and second evaluations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory/immediate memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage/forehead synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.677\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual spatial reasoning/mental rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecutive function/clock testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental arithmetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory/delayed memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggregate score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eICC, intra-group correlation coefficient; BOCA, Boston Cognitive Assessment.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Validity analysis\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1. Content validity\u003c/h2\u003e \u003cp\u003eThe correlation coefficient between the score of each BOCA subscale and the total BOCA scale score as between 0.202 and 0.751 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation coefficients between the subscale scores and total score for the BOCA scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory/immediate memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage/forehead synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual spatial reasoning/mental rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecutive function/clock testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental arithmetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory/delayed memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBOCA, Boston Cognitive Assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2. Calibration validity\u003c/h2\u003e \u003cp\u003eThe correlation coefficient between the total BOCA and MMSE scores was 0.682 (P\u0026thinsp;\u0026lt;\u0026thinsp;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\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation coefficients of the BOCA and MMSE scores of corresponding sub-cognitive domains\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory/immediate memory vs. memory ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage/forehead synthesis vs. attention and computational power\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention vs. attention and computational power\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirectional vs. directional force\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMMSE, Mini-Mental State Examination (MMSE); BOCA, Boston Cognitive Assessment.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe 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 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Cognitive impairment places a heavy burden on patients, the society, and the country [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Early recognition facilitates timely diagnosis, thereby guiding treatment and improving the quality of life [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, longitudinal monitoring of cognitive function is particularly important.\u003c/p\u003e \u003cp\u003eCurrent 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 [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], 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 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eForeign 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. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] 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. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] 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. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] 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.\u003c/p\u003e \u003cp\u003eIn 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 [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], age-related brain structure accelerates degradation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], the effectiveness of dopamine neurotransmission decreases, and the responses in the dominated brain functional area are delayed [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], 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 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which can effectively stimulate neural ability and improve individual tolerance to neuropathological changes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], 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\u0026rsquo;s skills in operating technology, which in turn improves test performance.\u003c/p\u003e \u003cp\u003eThe overall Cronbach\u0026rsquo;s α coefficient of the BOCA scale was 0.774, indicating that the scale had good internal reliability. In comparison, the Cronbach\u0026rsquo;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\u0026rsquo; understanding of the test questions, leading to measurement errors.\u003c/p\u003e \u003cp\u003eForty subjects were randomly selected in the study. After 1 month, the participants were evaluated again. The results showed that the overall test\u0026ndash;retest reliability was good, with an intra-group correlation coefficient of 0.796.\u003c/p\u003e \u003cp\u003eThe 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\u0026ndash;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.\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOCA\u0026nbsp;Boston Cognitive Assessment\u003c/p\u003e\n\u003cp\u003eICC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intra-group correlation coefficient\u003c/p\u003e\n\u003cp\u003eMMSE\u0026nbsp;Mini-Mental State Examination\u003c/p\u003e\n\u003cp\u003eMoCA\u0026nbsp;Montreal Cognitive Assessment\u003c/p\u003e\n\u003cp\u003eTICS \u0026nbsp; Telephone Interview for Cognitive Status\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Third Affiliated Hospital of Soochow University. \u0026nbsp;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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDesigning 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all participants of the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJia J, Wang F, Wei C, Zhou A, Jia X, Li F, et al. The prevalence of dementia in urban and rural areas of China. Alzheimers Dement. 2014;10(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia J, Zhou A, Wei C, Jia X, Wang F, Li F, et al. The prevalence of mild cognitive impairment and its etiological subtypes in elderly Chinese. 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Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(9):1450\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNasreddine ZS, Phillips NA, B\u0026eacute;dirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia L, Quan M, Fu Y, Zhao T, Li Y, Wei C, et al. Dementia in China: epidemiology, clinical management, and research advances. Lancet Neurol. 2020;19(1):81\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePan L, Wu Q, Zheng T. Utilization of outpatient service and its influencing factors among chronic disease patients in China: an Anderson model-based analysis. Chin J Public Health. 2021;37(9):1384\u0026ndash;8. 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BMC Neurol. 2022;22(1):92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Chen H, et al. The value of the Montreal Cognitive Assessment in diagnosing mild cognitive impairment. Chin J Geriatr. 2009;28(11):905\u0026ndash;7. (in Chinese).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia L, Du Y, Chu L, Zhang Z, Li F, Lyu D, et al. Prevalence, risk factors, and management of dementia and mild cognitive impairment in adults aged 60 years or older in China: a cross-sectional study. Lancet Public Health. 2020;5(12):e661\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeimer DL, Sager MA. Early identification and treatment of Alzheimer's disease: social and fiscal outcomes. Alzheimers Dement. 2009;5(3):215\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkaria AP. The economic and societal burden of Alzheimer disease: managed care considerations. Am J Manag Care. 2022;28(10 Suppl):S188\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLivingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMullins MA, Bynum JPW, Judd SE, Clarke PJ. Access to primary care and cognitive impairment: results from a national community study of aging Americans. BMC Geriatr. 2021;21(1):580.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBianchetti A, Ferrara N, Padovani A, Scarpini E, Trabucchi M, Maggi S. Timely Detection of Mild Cognitive Impairment in Italy: An Expert Opinion. J Alzheimers Dis. 2019;68(4):1401\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, Lin JS. Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(8):764\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu Y, Zhao S, Fan Z, Li Z, He F, Lin C, et al. Evaluation of the Mini-Mental State Examination and the Montreal Cognitive Assessment for Predicting Post-stroke Cognitive Impairment During the Acute Phase in Chinese Minor Stroke Patients. Front Aging Neurosci. 2020;12:236.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslam N, Hashem R, Gad M, Brown A, Levis B, Renoux C, et al. Accuracy of the Montreal Cognitive Assessment tool for detecting mild cognitive impairment: A systematic review and meta-analysis. Alzheimers Dement. 2023;19(7):3235\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia J, Zuo X, Jia XF, Chu C, Wu L, Zhou A, et al. Diagnosis and treatment of dementia in neurology outpatient departments of general hospitals in China. Alzheimers Dement. 2016;12(4):446\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoebuck-Spencer TM, Glen T, Puente AE, Denney RL, Ruff RM, Hostetter G, Bianchini KJ. Cognitive Screening Tests Versus Comprehensive Neuropsychological Test Batteries: A National Academy of Neuropsychology Education Paper\u0026dagger;. Arch Clin Neuropsychol. 2017;32(4):491\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMundt JC, Kinoshita LM, Hsu S, Yesavage JA, Greist JH. Telephonic Remote Evaluation of Neuropsychological Deficits (TREND): longitudinal monitoring of elderly community-dwelling volunteers using touch-tone telephones. Alzheimer Dis Assoc Disord. 2007;21(3):218\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasner M, Hermosillo E, Nasrini J, Saxena S, Dinges DF, Moore TM, Gur RC. Cognition test battery: Adjusting for practice and stimulus set effects for varying administration intervals in high performing individuals. J Clin Exp Neuropsychol. 2020;42(5):516\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerguson H, Turok N, Gold D, Vyshedskiy A, Piryatinsky I. A-303 Preliminary Analysis of the Influence of Age and Education on the Boston Cognitive Assessment (BoCA). Arch Clin Neuropsychol. 2022;37(6):1457.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChee MW, Chen KH, Zheng H, Chan KP, Isaac V, Sim SK, et al. Cognitive function and brain structure correlations in healthy elderly East Asians. NeuroImage. 2009;46(1):257\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Xia J, Ma C, Chen K, Xu K, Zhang J, et al. Accelerating Structural Degeneration in Temporal Regions and Their Effects on Cognition in Aging of MCI Patients. Cereb Cortex. 2020;30(1):326\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVolkow ND, Gur RC, Wang GJ, Fowler JS, Moberg PJ, Ding YS, et al. Association between decline in brain dopamine activity with age and cognitive and motor impairment in healthy individuals. Am J Psychiatry. 1998;155(3):344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern Y. Cognitive reserve in ageing and Alzheimer's disease. Lancet Neurol. 2012;11(11):1006\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern Y. Cognitive reserve. Neuropsychologia. 2009;47(10):2015\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern Y. What is cognitive reserve? Theory and research application of the reserve concept. J Int Neuropsychol Soc. 2002;8(3):448\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrison SL, Sajjad A, Bramer WM, Ikram MA, Tiemeier H, Stephan BC. Exploring strategies to operationalize cognitive reserve: A systematic review of reviews. J Clin Exp Neuropsychol. 2015;37(3):253\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Boston Cognitive Assessment, Healthy population, Effectiveness, Reliability","lastPublishedDoi":"10.21203/rs.3.rs-4821369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4821369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e 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\u0026ndash;retest reliability, content validity, and calibration validity were analyzed based on the relevant data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAge was moderately negatively correlated with BOCA scores, while length of education was moderately positively correlated with BOCA scores. The overall Cronbach\u0026rsquo;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\u0026ndash;retest reliability. The correlation coefficient between the scores of each BOCA item and the total score was between 0.202 and 0.751 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating good content validity. A moderate positive correlation was found between the total BOCA and MMSE scores (r\u0026thinsp;=\u0026thinsp;0.682, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating good calibration validity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e","manuscriptTitle":"A preliminary study on the use of the Boston Cognitive Assessment to assess cognitive function in a Chinese population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 13:07:41","doi":"10.21203/rs.3.rs-4821369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7c9b528-ca95-44ce-81a9-cdfaa8f20f35","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T06:08:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 13:07:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4821369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4821369","identity":"rs-4821369","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}