Bipolar Disorders 2014: 16: 326–336 © 2014 John Wiley & Sons A/S

Published by John Wiley & Sons Ltd.

BIPOLAR DISORDERS

Brief Report

Using the Brief Assessment of Cognition in

Schizophrenia (BACS) to assess cognitive
impairment in older patients with
schizophrenia and bipolar disorder
Cholet J, Sauvaget A, Vanelle J-M, Hommet C, Mondon K, Mamet J-P, Jennyfer Choleta, Anne Sauvageta,
Camus V. Using the Brief Assessment of Cognition in Schizophrenia Jean-Marie Vanellea, Caroline
(BACS) to assess cognitive impairment in older patients with Hommetb, Karl Mondonb,
schizophrenia and bipolar disorder. Jean-Philippe Mametc and
Bipolar Disord 2014: 16: 326–336. © 2014 John Wiley & Sons A/S. Vincent Camusb
Published by John Wiley & Sons Ltd. a
Po^le Universitaire d’Addictologie et de
Psychiatrie, CHU de Nantes, Universite de
Objectives: A growing body of evidence suggests that impairment in
Nantes, Nantes, bCHRU de Tours, Universite
cognitive functioning is an important clinical feature of both
Francß ois Rabelais de Tours, INSERM U930,
schizophrenia and bipolar disorder, and that these cognitive alterations
Tours, cNeuilly sur Seine, France
worsen with age. Although cognitive assessments are increasingly
becoming a part of research and clinical practice in schizophrenia, a
standardized and easily administered test battery for elderly patients
with bipolar disorder is still lacking. The Brief Assessment of Cognition
in Schizophrenia (BACS) captures those domains of cognition that are
the most severely affected in patients with schizophrenia and the most
strongly correlated with functional outcome. The primary aim of our
study was to investigate the clinical usefulness of the BACS in assessing
cognitive functioning in elderly euthymic patients with bipolar disorder, doi: 10.1111/bdi.12171
and to compare their cognitive profile to that of elderly patients with
schizophrenia. Key words: aging – assessment tool – BACS –
bipolar disorder – cognitive impairment
Methods: Elderly euthymic patients with bipolar disorder or
schizophrenia were assessed using the BACS and a standard cognitive Received 26 September 2012, revised and
test battery. accepted for publication 28 July 2013

Results: Fifty-seven elderly patients (aged 60 years and older) with Corresponding author:
bipolar disorder (n = 42) or schizophrenia (n = 15) were invited to Dr. Jennyfer Cholet
participate. All of the patients were assessed by the BACS as being Po^le Universitaire d’Addictologie et de
cognitively impaired. The patients with bipolar disorder scored Psychiatrie
significantly higher on the global scale and the verbal memory and Ho^pital Saint Jacques
attention sub-scores of the BACS than the patients with schizophrenia. 85 rue Saint Jacques
Nantes Cedex 1 44093
Discussion: The BACS appears to be a feasible and informative France
cognitive assessment tool for elderly patients with bipolar disorder. We Fax: 0033-2-40-84-61-18
believe that these preliminary results merit further investigation. E-mail: jennyfer.cholet@chu-nantes.fr

Bipolar disorder (BD) affects more than 1% of the
general population and is the sixth leading cause of
disability in developed countries (1, 2). Recent data
suggest that functional impairment in patients with
BD is remarkably prevalent, particularly with
regard to independent living, social relationships,
and vocational success (3, 4). Nearly 25% of
patients with BD end up going into nursing homes,
326
and 7.2% are hospitalized in long-term psychiatric
care facilities (5).
Cognitive impairment has been documented in
BD, psychotic mood disorders (6–9), and schizo-
phrenia (SCZ) (10), and is associated with worse
functional outcomes. Recent meta-analyses have
confirmed that cognitive impairment exists across
all bipolar mood states, including euthymia (11–

15). Several studies reported that neurocognitive
impairments in BD persist during remission, and
concerned mainly sustained attention (16), verbal
memory (17), and executive functions (7). A
recent meta-analysis (18) defined the cognitive
endophenotypes of euthymic patients with BD as
impairment in executive functions, especially flex-
ibility and inhibition, verbal memory, and
sustained attention. These recent data suggest
that patients with BD and patients with SCZ
share common features concerning cognition,
including executive functions, verbal memory,
and perceptual and motor functions (19–22).
With increasing age, the differences in cognitive
functioning between BD and SCZ seem more
quantitative than qualitative, and patients with
BD suffer from fewer cognitive disorders than
patients with SCZ (11, 12, 23). According to
Gildengers and colleagues (12), over 50% of
elderly patients with BD have documented cogni-
tive impairment. Furthermore, the evolution of
global cognitive aging in patients with BD may
lead to a specific form of dementia (24, 25) that
is independent of the incidence of neurodegenera-
tive disorders such as Alzheimer’s disease. Thus,
better assessments of cognitive functioning must
be developed to allow better detection of cogni-
tive impairment and to limit diagnostic errors.
Many confounding factors (26, 27) may con-
tribute to a worsening of cognitive performance,
including age, the patient’s comorbid environ-
ment, the severity of BD, an early onset (before
age 18 years) (28, 29), the polarity of the thymic
stage (30), the number of manic episodes (31),
the number of suicide attempts (32), a history of
psychosis, residual symptoms (especially depres-
sion), and associated comorbidities, such as
addictive disorders (33–35), anxiety disorders,
and cardiovascular disorders (36–38). The possi-
ble toxicity of specific treatments for BD (39–41)
must also be considered.
Although the assessment of cognition is
increasingly becoming an integral part of
research and clinical practice in SCZ, there is no
standardized and easily administered test battery
for elderly patients with BD. Although several
scales have been developed, they are limited by
their low sensitivity and specificity (42–44). How-
ever, the International Society for Bipolar Disor-
ders (ISBD) Cognition Committee has evaluated
the suitability of the Measurement and Treat-
ment Research to Improve Cognition in Schizo-
phrenia (MATRICS) Consensus Cognitive
Battery (MCCB) for use in BD, and proposed a
preliminary cognitive battery that could be used
internationally in research on BD (45). They
Using the BACS in older patients with BD
posit that the following four functions should be
evaluated in patients with BD using five of the
ten subtests of the MCCB: (i) psychomotor
speed, with Symbol Coding; (ii) executive func-
tions with the Trail Making Test (TMT)–part B
(TMT-B) and the Verbal Fluency Tests (semantic
and alphabetical); (iii) attention with the TMT–
part A (TMT-A); and (iv) visual learning with
the Brief Visuospatial Memory Test-Revised and
the Rey Osterrieth Complex Figure. They also
advocate further exploration of working memory
and verbal memory. Furthermore, they suggest
incorporating inhibition tests such as the Hayling
Sentence Completion Test (HSCT) and tests of
strategy and planning such as the Tower of Lon-
don Test.
The Brief Assessment of Cognition in Schizo-
phrenia (BACS) (46) meets the requirements set
out by the ISBD Cognition Committee. The tests
that they selected assess the cognitive domains
that are most severely impaired in SCZ and the
most strongly correlated with functional out-
come, particularly verbal memory using the List
Learning Task (number of words recalled per
trial), working memory using the Digit Sequenc-
ing Task (number of correct responses), executive
functions using the Verbal Fluency Test, invol-
ving the use of category instances and the con-
trolled oral word association test (number of
words generated per trial) and Tower of London
test (number of correct responses), attention
using Symbol Coding Test (number of correct
numerals), and motor speed using the Token
Motor Task (number of tokens correctly placed
into the container). The BACS is simple to use,
requiring only paper, pencils, and a stopwatch.
It can also be administered by different caregiv-
ers and takes approximately 35 min to complete.
This test battery was originally validated on a
sample of 150 patients with SCZ and compared
to a sample of 50 controls matched for age,
parental education, and ethnic group. A stan-
dard test battery was used as a reference to eval-
uate concurrent validity. At the end of these
validation procedures, the BACS presented satis-
factory psychometric properties with a good
completion rate and good test–retest reliability.
Its sensitivity was comparable to that of a
battery of tests requiring two hours or more to
complete. Furthermore, the global score on the
BACS was highly correlated with the global
score on the standard battery for patients and
controls alike. After accounting for age, gender
accounted for only 2% of the variance in the
composite scores. Moreover, it did not affect
test–retest reliability and was consistent when
327
Cholet et al.
repeated within the same patient. Perhaps more
important, the cognitive deficits measured by the
BACS are clinically relevant, as they are corre-
lated with patient variables related to living inde-
pendently and to functional capacity (47). Its
values were normalized in 2008, by the same
team, in patients up to 79 years of age (48). A
French version of the BACS was validated in
2007 (49).
We hypothesized that the BACS would meet the
requirements of the ISBD Cognition Committee
and could be used in elderly euthymic patients with
BD. To test this hypothesis, the results obtained
using the BACS were compared to those obtained
by a standard cognitive test battery. Moreover, the
BACS must be sensitive to confounding variables
encountered in the study of BD (e.g., the type of
BD, its severity, comorbidities, and types of treat-
ment). We also expected to find a correlation
between the scores on the BACS and the level of
psychosocial functioning. Finally, a high sensitivity
to the specific psychiatric diagnosis (BD versus
SCZ) was deemed to be useful.
Materials and methods
Study design
For this cross-sectional study, patients with BD or
SCZ were recruited by their psychiatrists from psy-
chiatric hospitals and psychiatric wards in the area
of Nantes and Tours (France). They were not
matched for age or gender. The patients underwent
two rounds of interviews, each lasting two hours,
within a maximum period of two weeks. Each
patient provided written informed consent prior to
participation.
Inclusion criteria
To be included in the study, the patients were
required to be at least 60 years of age. The patients
had to meet the DSM-IV-TR diagnostic criteria
(50) for either BD type I or II or SCZ. The diagno-
sis was confirmed by the Mini International Neu-
ropsychiatric Interview (MINI)-version 5.0.0 (51).
The patients also had to be euthymic and have
scores below 15 on the Montgomery– Asberg
Depression Rating Scale (MADRS) (52), below
nine on the Hamilton Depression Rating Scale
(HDRS) (53), below 15 on the Bech–Rafaelson
Mania Scale (MAS) (54), and below 20 on the
Young Mania Rating Scale (YMRS) (55). The
patients also had to have a composite score on the
Positive and Negative Syndrome Scale (PANSS)
below 15 or above +11 (56).
328
Exclusion criteria
Subjects whose native language was not French
were not included in the study. Patients with
schizoaffective disorders were not included. Any
disease that may have affected cognitive functions
(e.g., stroke, epilepsy, neurodegenerative diseases,
Parkinson’s disease, brain metastases, unbalanced
metabolic or endocrine diseases, and uncontrolled
arterial blood pressure) was considered grounds
for exclusion. A delay of less than 20 weeks
between the completion of the tests and the last
session of electroconvulsive therapy (ECT) was
also a criterion for exclusion. Dependence on a
psychoactive substance, excluding tobacco, in the
last six months and acute intoxication due to psy-
choactive substance use in the month preceding the
completion of the cognitive assessment also consti-
tuted reasons for exclusion.
Cognitive assessment
Each patient completed the BACS and a standard
cognitive test battery, including the Mini Mental
State Examination (MMSE) (57), the Mattis
Dementia Rating Scale (DRS) (58), the Clock
Drawing Test (CDT) (59), the Hayling Sentence
Completion Test (HSCT) (60), the TMT–A and
TMT–B (61), and the Rey Complex Figure Test
(RCFT) (copy and recall) (62). French normative
data for the DRS are lacking but a score was con-
sidered pathological if it was below 141 (63).
Psychosocial functioning
Functional outcomes were evaluated by the follow-
ing assessment tools: Activities of Daily Living
(ADL) (64), Instrumental Activities of Daily Liv-
ing (I-ADL) (65), Social Activities of Daily Living
(S-ADL) (66), and Global Assessment of Func-
tioning (GAF) scale (67).
Additional data
We collected sociodemographic data on age, gen-
der, educational level, number of years worked,
and number of years spent living in institutions
(foster homes, retirement homes, and long-term
psychiatric hospitalizations).
We estimated the severity of BD based on the
type of BD, the age of onset, which corresponded
to the first contact with psychiatric services
(consultation or hospitalization), the number of
hospitalizations, the total time spent in hospitals,
and the history of ECT or lithium therapy. The
presence and type of somatic and psychiatric com-
orbidities were also recorded.

Statistical analysis
Scores on the TMT-A and TMT-B were standard-
ized, using the conversion table of Poitrenaud and
colleagues (68). BACS total and sub-scale scores
were transformed and adjusted for age using pub-
lished normative data (48). Adjusting for age
enabled us to investigate the specific roles of BD
and comorbidities that may accelerate cognitive
decline beyond the effects of normal aging.
We analyzed the data using SAS/STAT (SASâ
software, SAS version 9.2; SAS Institute, Cary,
NC, USA). Due to the exploratory nature of our
pilot study and our sample size, our objective was
to evaluate the feasibility of using the BACS in
elderly patients with BD using non-parametric
tests and univariate analyses; our aim was neither
to test the validity of the BACS per se nor to evalu-
ate its internal consistency. The means were com-
pared using the Wilcoxon test. Differences were
considered statistically significant at p < 0.05.
Spearman’s rank correlation coefficient (R),
adjusted on Fisher’s exact test, was used to evalu-
ate the association between the scores obtained on
the BACS and the standard cognitive test battery
and between the scores obtained on the BACS and
the results obtained on the functional scales.
Hypothesis tests were considered statistically sig-
nificant for a correlation coefficient (R) greater
than 0.3 associated with p < 0.05.
This protocol was approved by the Ethics Com-
mittee of Tours (France).
Results
All of the 42 patients with BD and 15 patients with
SCZ completed the full battery of cognitive assess-
ments.
The mean age of the patients with BD (28
females) was 70.2 years, and the vast majority
(n = 38) were younger than 80 years of age. Of the
patients with BD, 9.5% had early-onset BD and
Table 1. Demographic data for patients with bipolar disorder and schizophrenia
Bipolar disorder
Age, years, mean (SD)
Age at onset, years, mean (SD)
Hospitalizations, mean (SD)
Total number
Time spent, days 651.6 (1,103.7)
Educational level, years, mean (SD)
Duration of employment, years, mean (SD)
Treatment by ECT, %
Duration of lithium therapy, years, mean (SD)
History of suicide attempt, %
No. of suicide attempts, mean (SD)
ECT = electroconvulsive therapy; NS = non-significant (p > 0.10); SD = standard deviation.
Using the BACS in older patients with BD
45.2% had a late-onset form of BD (diagnosed
after the age of 45). BD type I predominated
(64.3%). Less than 20% of the patients with BD
were currently, or had previously been, institution-
alized. Moreover, 28.6% of the patients with BD
belonged to a high polyvascular risk category.
Additionally, 23.8% of the patients had an associ-
ated anxiety disorder and 4.8% had a history of
psychoactive substance use. Half of the patients
with BD had a history of lithium therapy.
The mean age of the patients (ten females) with
SCZ was 68.8 years. In this cohort, 14.3% had
early-onset SCZ and 14.3% had late-onset SCZ.
Forty percent were currently, or had previously
been, institutionalized. One-third of the patients
with SCZ were in a high polyvascular risk category
and three of the patients (20%) had an associated
anxiety disorder. None of the patients suffered
from a substance use disorder, not including
tobacco use.
Tables 1 and 2 present the demographic and
psychosocial data for the BD and SCZ groups,
respectively. The results, in both groups, from the
standard cognitive test battery are shown in
Table 3, and from the BACS in Table 4.
As the correlations between the BACS and the
demographic data, the psychosocial data, and the
standard cognitive battery are well known for
patients with SCZ, we studied the correlations with
the BACS for the BD group alone.
Correlations between the BACS and the demographic
and psychosocial data for patients with BD
Age was correlated positively with the overall score
on the BACS and its List Learning, Verbal Fluen-
cy, particularly the categorical fluency, and the
Symbol Coding Test sub-scores. This correlation
was no longer statistically significant when we used
the adjusted-for-age scores (Z-scores) on the
BACS.
Schizophrenia p-value
70.2 (7.2) 68.8 (7.4) NS
41.2 (17.6) 28.4 (11.4) < 0.05
11.0 (12.9) 15.8 (16.1) NS
2,143.9 (3,454.5) 0.10 < p < 0.05
8.8 (3.8) 7.9 (4.7) NS
26.3 (14.8) 14.4 (12.4) 0.10 < p < 0.05
26.2 6.7 NS
8.2 (12.4) 0 < 0.01
50 20 0.10 < p < 0.05
1.0 (1.2) 0.3 (0.6) 0.10 < p < 0.05
329
Cholet et al.

Table 2. Psychosocial data for patients with bipolar disorder and schizophrenia

Bipolar disorder Schizophrenia

Measures Average Range SD Average Range SD p-value

HDRS 3.9 0–8 2.4 4.9 1–8 2.0 NS

MADRS 4.1 0–13 3.4 2.5 0–7 2.1 NS
MAS 1.7 0–5 1.8 1.1 0–5 1.5 NS
YMRS 3.5 0–11 3.0 2.7 0–8 2.9 NS
PANSS: composite score 2.0 12 to +10 4.7 1.3 10 to +6 4.5 NS
GAF 65.2 30–90 17.1 45.1 21–70 18.0 < 0.01
ADL 6.6 6–11 1.3 7.4 6–11 1.8 NS
I-ADL 15.6 9–36 6.3 23.3 9–35 8.6 < 0.01
S-ADL 9.8 6–19 4.0 13.8 6–22 5.4 < 0.05

ADL = Activities of Daily Living; GAF = Global Assessment of Functioning Scale; HDRS = Hamilton Depression Rating Scale;
I-ADL = Instrumental Activities of Daily Living; MADRS = Montgomery–
Asberg Depression Rating Scale; MAS = Bech–Rafaelson Mania
Scale; NS = non-significant (p > 0.10); PANSS = Positive and Negative Syndrome Scale; S-ADL = Social Activities of Daily Living;
SD = standard deviation; YMRS = Young Mania Rating Scale.

Table 3. Results of the standard cognitive test battery for patients with bipolar disorder and schizophrenia

Bipolar disorder Schizophrenia

Measures Average Range SD Average Range SD p-value

MMSE 26.0 30–18 3.1 23.8 11–29 4.8 NS

TMT–A, standardized score 4.5 1–8 2.3 3.3 1–7 2.1 0.10 < p < 0.05
TMT–B, standardized score 3.6 1–10 2.5 2.3 0–7 2.1 0.10 < p < 0.05
Clock Drawing Test, standardized score 25.8 10–33 8.3 21.9 0–34 10.8 NS
HSCT
First part: time, sec 58.1 44–98 12.7 72.2 51–112 18.3 < 0.01
Inhibition: errors, number 4.4 0–15 4.6 8.3 0–15 5.2 < 0.01
Dementia Rating Scale
Global score 126.6 88–144 12.5 111.9 68–142 23.1 < 0.05
Attention 35.4 31–37 1.2 33.6 25–37 3.6 NS
Initiation 31.0 14–37 6.7 26.2 11–37 8.0 0.10 < p < 0.05
Construction 5.8 3–6 0.6 4.5 0–6 2.3 < 0.05
Concept 33.2 19–39 4.6 29.7 15–38 7.6 NS
Memory 21.2 13–25 2.7 17.93 6–25 4.9 < 0.01
Rey Complex Figure Test
Copy: score 28.7 11–38 6.1 22.5 1–36 13.2 NS
Recall: score 9.9 4–24 6.0 8.4 0–20 6.3 NS
Copy: time, sec 346.9 43–1,650 286.1 298.9 115–922 208.4 NS

HSCT = Hayling Sentence Completion Test; MMSE = Mini Mental State Examination; NS = non-significant (p > 0.10); SD = standard
deviation; TMT–A = Trail Making Test–part A; TMT–B = Trail Making Test–part B.

The overall BACS score was significantly corre-
lated with the level of education, regardless of age
(R = 0.48, p = 0.004). Sub-scores of List Learning
(R = 0.34, p = 0.04), the Digit Sequencing
Task (R = 0.39, p = 0.02), Verbal Fluency
(R = 0.46, p = 0.007), and Symbol Coding Test
(R = 0.53, p = 0.002) were also correlated with the
educational level when age was included as a con-
founder. The Tower of London test scores were
not correlated with the level of education.
The type of BD was not correlated with any of
the cognitive data. Earlier onset was negatively
correlated with the Z-scores for the Token Motor
330
Task (R = 0.48, p = 0.004) and the Tower of
London test (R = 0.37, p = 0.03).
Correlations between the BACS and the standard
cognitive battery test for patients with BD
The global score on the BACS was positively cor-
related with all the results from the standard bat-
tery tests (Table 5). The List Learning Z-scores, in
particular, were strongly correlated with the mem-
ory sub-scores of the DRS. The Digit Sequencing
Task sub-scores were highly correlated with the
TMT–B, the conceptual sub-score of the DRS, and
 Using the BACS in older patients with BD

Table 4. Results of the Brief Assessment of Cognition in Schizophrenia (BACS) for patients with bipolar disorder and schizophrenia

Bipolar disorder Schizophrenia

Measures Average Range SD Average Range SD p-value

BACS
Global score 160.6 80–275 50.6 127.7 28–222 57.1 0.10 < p < 0.05
List Learning 29.8 5–60 10.9 22.7 8–44 10.1 < 0.05
Digit Sequencing Task 13.9 7–27 5.2 13.1 4–25 6.3 NS
Token Motor Task 45.0 10–74 14.1 34.6 4–56 15.8 < 0.05
Verbal Fluency 34.3 11–69 14.1 28.5 6–49 14.3 NS
Semantic 17.6 7–31 6.7 14.1 4–23 6.7 NS
Alphabetical 16.8 5–39 8.4 14.5 2–31 9.1 NS
Symbol Coding 25.5 2–60 13.8 19.5 1–55 15.8 NS
Tower of London Test 12.2 5–19 3.4 9.2 1–19 5.8 0.10 < p < 0.05
BACS, Z-scores
Global score 2.0 5.1 to +1.1 1.5 3.0 0.2 to 5.9 1.8 0.10 < p < 0.05
List Learning 1.2 4.1 to +1.5 1.1 2.0 3.6 to 0 1.0 < 0.05
Digit Sequencing Task 1.4 4.3 to +1.7 1.3 1.6 4.0 to +1.2 1.6 NS
Token Motor Task 1.1 2.6 to +0.9 0.9 1.9 3.6 to +0.1 1.0 < 0.05
Verbal Fluency 1.0 2.9 to +1.4 1.1 1.4 3.4 to +0.2 1.1 NS
Symbol Coding 2.3 4.9 to +1.1 1.5 2.9 5.3 to +0.5 1.7 NS
Tower of London Test 0.8 2.8 to +1.0 0.9 1.6 3.6 to +0.8 1.5 NS

NS = non-significant (p > 0.10); SD = standard deviation.

the inhibition part of the HSCT. The Token Motor
Task Z-scores were correlated with the TMT-A.
The sub-scores of the Symbol Coding Test were
positively correlated with all the other results. The
alphabetical Verbal Fluency Z-score was strongly
positively correlated with the TMT–B, the inhibi-
tion part of the HSCT, and the CDT. Conversely,
the semantic Verbal Fluency Z-score was corre-
lated with the sub-scores of initiation and concepts
in the DRS, the TMT-B, and the RCFT. The sub-
scores of the Tower of London test were correlated
with all the other results, particularly with the
TMT–B, the global score of the DRS, and the initi-
ation sub-score of the DRS.
Correlations with therapeutic history data for patients
with BD
Hospitalizations. All of the BACS Z-scores
(R = 0.63 to 0.38; p = 0.0002, p = 0.03), except
for Verbal Fluency (including categorical fluency
and alphabetical fluency), were negatively corre-
lated with the number of hospitalizations. The
total duration of hospitalizations was negatively
correlated with all the sub-scores of the BACS
(R = 0.66 to 0.38; p ≤ 0.0001 to p = 0.02).
Treatments. Patients with BD with a history of
lithium therapy were significantly less successful on
the Token Motor Task (R = 0.30) than patients
without a history of lithium therapy, but the
observed difference did not reach statistical signifi-
cance (p = 0.07). The overall scores on the BACS
for the two subgroups of patients with BD (with
and without lithium therapy) were statistically
comparable.
A history of ECT was not correlated with the
MMSE or DRS scores. Although the global score
on the BACS was, on average, lower in patients
with than in patients without a history of ECT, the
difference in this score was not statistically signifi-
cant (p = 0.09). However, patients with a history
of ECT performed significantly lower on the
Token Motor Task compared to patients with no
history of ECT (p = 0.04). Moreover, patients with
no history of ECT were more successful on the
Tower of London Test and the test of semantic
Verbal Fluency than the patients with a history of
ECT, although not to a statistically significant
degree (both p = 0.06).
Comparison between patients with BD and patients
with SCZ
The patients with BD completed the first part of
the HSCT more quickly and made fewer errors
during the inhibition part compared to patients
with SCZ. Patients with BD had higher scores on
the DRS than patients with SCZ. Their scores on
the TMT–A and TMT–B were significantly higher
than those of patients with SCZ. The two groups
performed similarly on the RCFT and the MMSE
(Table 3).
The patients with BD also attained signifi-
cantly higher global scores on the BACS and
List Learning and Token Motor Task sub-
331
Cholet et al.
scores. Although they also performed better on
the Tower of London Test compared to patients
with SCZ, this difference did not reach statistical
significance when the Z-scores were compared
(Table 4).
The GAF score was higher among patients with
BD, but the I-ADL and S-ADL scores were higher
among patients with SCZ (Table 2). Nevertheless,
the GAF scores were positively correlated with the
Z-scores of the BACS, especially the global score.
The ADL scores were negatively correlated with all
the Z-scores of the BACS, particularly with Verbal
Fluency, but not with the List Learning and the
Symbol Coding Test. The I-ADL score and all of
the Z-scores of the BACS, except for the Digit
Sequencing Task, were negatively correlated. The
S-ADL score was negatively correlated with all the
Z-scores of the BACS, and strongly negatively cor-
related with the Tower of London Test (Table 5).
Discussion
Our study showed that the cognitive profiles of
elderly patients with SCZ and BD differ quantita-
tively rather than qualitatively. Although we did
not include healthy control subjects in our study,
the normative data for the BACS (48) allowed us
to conclude from our data that the cognitive profile
of elderly patients with BD is intermediate between
the profiles of patients with SCZ and those of the
general population. The global Z-score of the
BACS was also higher for the patients with BD
( 1.99 SD) than for those with SCZ. Elderly
patients with SCZ had greater impairment in ver-
bal memory and attentional abilities than older
patients with BD. These results are consistent with
those of recent studies (14, 15, 21, 69–71). Interest-
ingly, the BACS seems to have sufficient sensitivity
to differentiate between the cognitive impairment
of elderly patients with SCZ and with BD. How-
ever, adjusted analyses, in particular on the
number of hospitalizations in a larger sample size,
are needed to confirm this conclusion.
Elderly euthymic patients with BD have cogni-
tive impairment concerning memory, attention,
executive function, and speed processing. Our
observations cannot be explained by the effects of
age alone because the results survive adjustment
for age. Moreover, our observations are consistent
with those in previous reports in the literature (7,
16–22) and provide further evidence of the exis-
tence of cognitive endophenotypes that are com-
mon to patients with BD, regardless of their age (1,
7, 16). Of note, correlations between the BACS
and the standard screening batteries (MMSE and
DRS) were strong and positive, as were correla-
332
tions between each sub-score of the BACS and the
standardized tests evaluating the same cognitive
domains. Thus, our results revealed that the BACS
is a useful and promising tool for the assessment of
cognitive functioning in elderly patients with BD.
Our pilot study did not allow us to distinguish
the possible effects of BD type, the age at onset,
the iatrogenic effect of lithium, and the cumulative
effect of mood episodes and number of hospitaliza-
tions (39–41). However, the scores obtained on the
BACS were negatively correlated with the severity
of bipolar illness (based on an estimate obtained
using the age at onset and the number and dura-
tion of hospitalizations) and a history of ECT. Our
results confirmed those in previous reports describ-
ing the detrimental effect of bipolar illness on glo-
bal cognitive functioning (1, 32–35, 40).
Interestingly, the BACS appears to be sensitive
enough to detect these manifestations of the ill-
ness.
Correlations between the BACS global score
and scores on the GAF, ADL, I-ADL, and S-ADL
provide additional evidence that the BACS global
score may be a good indicator of psychosocial
functioning of elderly patients with BD. Correla-
tion between BACS and psychosocial functioning
scores is consistent with recent data reported in the
literature (1, 5, 70, 71) and highlights the
deleterious functional impact of the cognitive
impairment affecting patients with BD. We found
no correlation between BACS scores and any of
the thymic scales (MADRS, HDRS). The exclu-
sion of patients who scored highly on these scales
may explain this finding as only a few residual
depressive symptoms may have been present in the
patients who were included in the research.
As our study was of an exploratory nature, there
were some important limitations. First, the small
sample size may have caused the study to be
under-powered and restricted us to performing
only univariate, nonparametric analyses, as
opposed to multivariate statistics. Indeed, the
small sample size did not allow us to adjust our
analysis to take account of several potential con-
founding factors such as BD type, the age at onset,
and the number of hospitalizations. Moreover, we
were not able to explore the effects of somatic and
addictive comorbidities, or of treatments received
during the course of the patients’ illness.
Second, we did not use any randomization
between groups. All the patients were referred to
us by their respective psychiatrists based on the cri-
teria for inclusion and the predicted ability for the
patient to achieve the full battery of tests. Thus,
only those patients who were the most interested in
participating in the study and the most likely to be
 Table 5. Correlations between the results of the Brief Assessment of Cognition in Schizophrenia (BACS) and the standard cognitive test battery and the functional scores for patients with bipolar disordera

HSCT DRS RCFT RCFT

first HSCT global DRS DRS DRS DRS DRS copy recall
Correlations MMSE TMT–A TMT–B CDT part inhibition score attention initiation construction concept memory score score GAF ADL I-ADL S-ADL

BACS
Global score 0.60 0.78 0.86 0.56 0.61 0.58 0.85 0.36 0.82 0.50 0.56 0.61 0.64 0.61 0.60 0.49 0.55 0.67
List Learning 0.58 0.56 0.71 0.46 0.51 0.52 0.57 0.13 0.48 0.43 0.31 0.54 0.56 0.66 0.54 0.21 0.39 0.50
Digit Sequencing 0.54 0.58 0.63 0.44 0.34 0.52 0.59 0.43 0.48 0.44 0.59 0.46 0.55 0.36 0.41 0.40 0.23 0.40
Task
Token Motor Task 0.42 0.58 0.64 0.47 0.42 0.37 0.67 0.31 0.64 0.33 0.43 0.48 0.52 0.51 0.42 0.46 0.46 0.53
Verbal fluency 0.57 0.72 0.71 0.50 0.64 0.53 0.79 0.27 0.80 0.49 0.48 0.60 0.47 0.55 0.44 0.47 0.50 0.57
Semantic 0.59 0.65 0.72 0.47 0.62 0.52 0.78 0.20 0.78 0.44 0.52 0.51 0.48 0.57 0.44 0.46 0.55 0.48
Alphabetical 0.44 0.72 0.64 0.46 0.61 0.53 0.69 0.30 0.68 0.49 0.42 0.58 0.40 0.49 0.39 0.40 0.47 0.59
Symbol Coding 0.34 0.74 0.75 0.42 0.57 0.48 0.75 0.36 0.73 0.47 0.61 0.42 0.50 0.39 0.53 0.40 0.50 0.54
Tower of London 0.45 0.61 0.73 0.59 0.30 0.55 0.73 0.34 0.68 0.37 0.54 0.36 0.53 0.58 0.58 0.33 0.42 0.65
Test
BACS, Z-scores
Global score 0.58 0.71 0.82 0.55 0.49 0.62 0.81 0.36 0.75 0.45 0.53 0.57 0.62 0.61 0.65 0.39 0.43 0.69
List Learning 0.65 0.51 0.69 0.43 0.47 0.53 0.54 0.04 0.43 0.45 0.25 0.60 0.56 0.67 0.53 0.20 0.33 0.49
Digit Sequencing 0.53 0.54 0.61 0.38 0.29 0.51 0.55 0.35 0.44 0.39 0.54 0.43 0.50 0.42 0.40 0.32 0.21 0.43
Task
Token Motor Task 0.31 0.48 0.58 0.42 0.35 0.27 0.60 0.26 0.62 0.22 0.28 0.35 0.50 0.52 0.47 0.36 0.34 0.57
Verbal fluency 0.56 0.64 0.75 0.47 0.54 0.55 0.76 0.24 0.77 0.48 0.46 0.61 0.41 0.52 0.39 0.44 0.41 0.54
(semantic and
alphabetical)
Symbol Coding 0.34 0.65 0.67 0.39 0.46 0.46 0.69 0.30 0.68 0.41 0.57 0.35 0.43 0.38 0.56 0.25 0.36 0.49
Tower of London 0.51 0.58 0.72 0.59 0.20 0.54 0.72 0.29 0.66 0.36 0.52 0.40 0.52 0.59 0.54 0.35 0.37 0.63
Test

ADL = Activities of Daily Living; CDT = Clock Drawing Test; DRS = Dementia Rating Scale; GAF = Global Assessment of Functioning Scale; HSCT = Hayling Sentence Completion Test; I-
ADL = Instrumental Activities of Daily Living; MMSE = Mini Mental State Examination; RCFT = Rey Complex Figure Test; S-ADL = Social Activities of Daily Living; TMT–A = Trail Making Test
–part A; TMT–B = Trail Making Test–part B.
a
Spearman correlation analysis, adjusted on Fisher’s exact Test with p < 0.05.

333
Using the BACS in older patients with BD
Cholet et al.
able to withstand four hours of testing were
recruited. Some authors have suggested that the
number of suicide attempts may influence the cog-
nitive profile of patients with BD (32). In our
study, only a few patients with BD had made sui-
cide attempts, thereby precluding us from analyz-
ing the possible confounding effects of being a
‘survivor’. Moreover, our patients were recruited
from a specific geographical region, possibly intro-
ducing a geographical bias. Therefore, we remain
cautious about generalizing our results to broader
populations of elderly patients with BD.
Third, our study design may have had limita-
tions. The long duration of the interviews may
have altered the patients’ test performance and
introduced errors, although the patients were
given the option to take breaks as needed. More-
over, they were asked to attend for two separate
interviews. Although an assessment of thymic
state occurred at each visit, we cannot rule out
the possibility that we failed to consider the wide
individual variability in cognitive impairment,
described by Depp and colleagues (71), in the
short term. In addition, the same examiner
administered all of the tests, and the GAF was
performed at the end of the second interview; this
approach may have introduced an examiner bias,
leading us to underestimate the GAF score in
light of the results obtained on the cognitive
functioning tests.
The recommendations by the ISBD Cognition
Committee highlight the importance of developing
a specific cognitive scale both for patients with BD
and with SCZ. According to this committee, this
scale should assess psychomotor speed (e.g., Sym-
bol Coding Test), executive functions (e.g., Verbal
Fluency and Tower of London Test), attention
(e.g., Token Motor Task), verbal memory (e.g.,
List Learning), working memory (e.g., Digit
Sequencing Task), and visual memory (45). The
BACS assesses all of the above-mentioned cogni-
tive domains, except for visual memory. However,
the results of our study showed that the BACS
scores are correlated with visual memory, as
assessed by recall on the RCFT. This finding raises
important questions concerning the role and
importance of visual memory in executive func-
tions. Thus, the relevance of adding a test of visual
memory for elderly patients with BD may be ques-
tionable. The ISBD Cognition Committee also call
into question the value of assessing cognitive inhi-
bition, particularly using the HSCT. Considering
that the results of the HSCT appear to be corre-
lated with several sub-scores of the BACS, the
HSCT likely tests a combination of several major
cognitive functions that are evaluated separately in
334
the BACS. In addition, the Tower of London Test
does not appear to be correlated with the subjects’
educational level, and the latter can be measured
more reliably. Thus, we posit that the HSCT could
be administered as a second-line test in elderly
patients with BD, particularly if the result obtained
using the Tower of London Test is correct.
Conclusions
The BACS may be a valuable neuropsychological
instrument for assessing global cognition in elderly
patients with BD, with a high sensitivity for detect-
ing cognitive manifestations of the BD process.
Moreover, the global score may serve as a power-
ful indicator of functional outcome. Due to its
brevity (under 35 min) and its higher sensitivity
compared to the MMSE, the BACS could effec-
tively be integrated into a psychiatric follow-up
consultation. These results are promising and merit
replication in a larger sample to better explore the
impact of potential confounding factors such as
BD type, the age at onset, the number of hospital-
izations, the treatments (especially lithium), and
aging. Finally, the results of our study incorporate
the most recent data from the literature (72), and
emphasize the importance of developing special-
ized care tailored to patients with BD, with the aim
of preventing the emergence of cognitive disorders
and downstream effects on psychosocial function-
ing. Our study also raises the possibility that pre-
vention strategies against cognitive impairment
used in SCZ, such as cognitive rehabilitation and
functional remediation (73), could be adapted to
help patients with BD.
Disclosures
The authors of this paper do not have any commercial associa-
tions that might pose a conflict of interest in connection with
this manuscript.
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