Table 3.

Domain 2 Limitations of Brief Cognitive Assessments (BCAs): themes and exemplary quotes

Themes	Quotes
Access to neuropsychology is limited, and BCAs are primarily administered by medical specialists	Neuropsychologist, Europe: But I’m not very sure about the other cities of [country], and even more in [other parts of the country], there are no professionals – neuropsychologists in these – in these places unfortunately. Neurologist, South America: … more or less five to ten percent of [my] patients reached the neuropsychologist’s office.
Current BCAs are too long for widescale application	Neurologist, Middle East: Well, I think there are some people that are aware of it [BCA]. But using it is a different thing. Like, when I was in primary care, it’s difficult for you to keep using it on every patient to screen them. It’s tough for a physician with the short period of time that you have. Neurologist, South America: It takes us 20 to 25 minutes. Impossible, in usual practice.
Current BCAs are either not or poorly validated	Neurologist, Africa: So, look, we don’t have that much normative data. Though, I think there has been a study with [BCA] in [country] from years back by a U.S. group. And so, we have limited normative data, really. Neurologist, Asia: That’s [normative data] lacking. That’s, really, lacking.
Poor applicability due to language, education, and literacy variables	Psychiatrist, North America: Well yes, although I think the best thing to improve would be education, in the meantime, we need to serve those with low education. So, we need to have tools that are not biased by education so that we don’t confuse who has dementia and who does not. We cannot apply the same test with the same norms to a farmer, an illiterate person, and a doctor in math. I think we need to have specific instruments for each one of them because people that have a lot of intellectual resources are going to mock a test designed for an illiterate person. Neurologist, Middle East: The language is different, so that’s a challenge. I was trained in the [country]. We used to use [BCAs]. And here in [country], it’s tough to translate that in [local language] and try to get all these things together. Neurologist, South America: And one of the limitations for us here in [country] is schooling, for example, [BCA 1] is a good test with good schooling, at least 8 years of schooling. Below that, it starts to be a test that can give you false positives. So, it is not a good test for under 4 years, for example, it is very bad. Then it is said that you can give it an extra point. It doesn’t help, the patient is still diagnosed with dementia, so one needs to be careful. [BCA 2] is better with regard to education, but it is bad because it does not detect cognitive decline in individuals with more education. It has a low sensitivity in individuals with higher education.
Poor applicability due to cultural biases	Neurologist, Asia: I think social conventions would also be a challenge, because we don’t react the same, we might not have the same priorities of moral values in mind. That’s because of our avocation or the societal cultural beliefs. Neurologist, Africa: So, again, some of the photographs and all that in that [stimulus] book, like for facial memory, obviously, they are not at all culturally appropriate. They [face stimuli] are all White. So, that’s a downside to that.
Limited diagnostic accuracy and sensitivity to severity	Neuropsychologist, Europe: I’m not a fan of short tests screening tests because OK we can have a first glance of the elder, but this distinction between who has SCI and who has late MCI and who has pre-dementia, it’s difficult to - to understand it only with short screening tests. Geriatrician, Asia: We use [BCA] a lot which has low sensitivity in mild impairment, so we could miss some cases as well.