Kettle Test—A Brief Measure of Cognitive Functional ... Test (Hartman-Maeir, Armon, & Katz, 2005),...

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592 September/October 2009, Volume 63, Number 5 Kettle Test—A Brief Measure of Cognitive Functional Performance: Reliability and Validity in Stroke Rehabilitation KEY WORDS • cognition • reproducibility of results • stroke • task performance and analysis Adina Hartman-Maeir, PhD, OT, is Lecturer, School of Occupational Therapy, Hadassah and Hebrew University, Mount Scopus, POB 24026, Jerusalem 91240 Israel; [email protected] Hagit Harel, MSc, OT, is Clinician, Rehabilitation Department, Sheba Medical Center, Tel Aviv, Israel. Noomi Katz, PhD, OTR, is Director, Research Institute for Health and Medical Professions, Ono Academic College, Israel, and Professor Emeritus, School of Occupational Therapy, Hadassah and Hebrew University, Jerusalem, Israel. OBJECTIVES. We examined the reliability and validity of the Kettle Test, a brief performance measure based on a complex everyday task designed to tap into basic and higher level cognitive processes. METHOD. Participants included 21 people attending stroke rehabilitation and 4 occupational therapists for the reliability analysis, 36 people at discharge from stroke rehabilitation, and 36 age-matched healthy control participants for the validity analyses. Instruments included a battery of conventional cognitive measures and functional outcomes. RESULTS. Interrater reliability was found to be high. Stroke survivors at discharge from rehabilitation were found to require significantly more assistance on the Kettle Test than control participants (p < .000); their scores on the Kettle Test were significantly and moderately correlated with the conventional cognitive and functional outcome measures. CONCLUSIONS. The results support the reliability and validity of the Kettle Test as a top-down measure of cognition-in-function in people at discharge from stroke rehabilitation. Hartman-Maeir, A., Harel, H., & Katz, N. (2009). Kettle Test—A brief measure of cognitive functional performance: Reliability and validity in stroke rehabilitation. American Journal of Occupational Therapy, 64, 592–599. Adina Hartman-Maeir, Hagit Harel, Noomi Katz P eoplewithacquiredbraininjuryareathighriskforcognitiveimpairmentsthat haveadetrimentalimpactonoccupationalperformance(Ciceroneetal.,2005; Donnovanetal.,2008;Hershkovitz&Brill,2007;Zinnetal.,2004).Occupational therapy has developed a unique body of knowledge regarding the relationship between cognition and occupation involving occupation-based, client-centered intervention (Gillen, 2009; Katz, 2005). Conventional “tabletop” measures of cognitionarevaluablediagnosticallybuthavelimitedecologicalvalidityanddo notfullyaddressthefunctionalimplicationsofcognitivedeficits.Moreover,the interdisciplinaryrehabilitationcommunityhasemphasizedtheneedforecologi- callyvalidmeasuresofcognitioninfunction(Burgessetal.,2006).Thiscurrent emphasisisanimportantmilestoneintheconceptualizationofmeasurementin health-relatedprofessions.Instrumentsthatfollowthesedirectivesareessentialand are integral to the occupational therapy philosophy and practice (American OccupationalTherapyAssociation,2008).Occupationaltherapyisinaunique positiontofulfillacentralroleinthisdevelopmentandisestablishingitsexpertise inthedevelopmentoftop-downassessments(Hartman-Maeir,Katz,&Baum, 2009;Law,Baum,&Dunn,2005). Evaluationofoutcomesinstrokerehabilitation,beyondbasicactivitiesofdaily living(BADLs),hasbecomeextremelyimportantasmorepeoplesurvivestrokeand returntotheirhomesinthecommunity.Oneprimaryconcernatdischargefrom rehabilitationispredictingtheabilitytofunctionindependentlyinthecommunity orthedegreeofassistancerequiredtodoso.Instrumentalactivitiesofdailyliving Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930156/ on 10/09/2018 Terms of Use: http://AOTA.org/terms

Transcript of Kettle Test—A Brief Measure of Cognitive Functional ... Test (Hartman-Maeir, Armon, & Katz, 2005),...

Page 1: Kettle Test—A Brief Measure of Cognitive Functional ... Test (Hartman-Maeir, Armon, & Katz, 2005), a brief performance measure that is based on a complex everyday task and is designed

592� September/October 2009, Volume 63, Number 5

Kettle Test—A Brief Measure of Cognitive Functional Performance: Reliability and Validity in Stroke Rehabilitation

KEY WORDS• cognition• reproducibility of results• stroke• task performance and analysis

Adina Hartman-Maeir, PhD, OT, is Lecturer, School of Occupational Therapy, Hadassah and Hebrew University, Mount Scopus, POB 24026, Jerusalem 91240 Israel; [email protected]

Hagit Harel, MSc, OT, is Clinician, Rehabilitation Department, Sheba Medical Center, Tel Aviv, Israel.

Noomi Katz, PhD, OTR, is Director, Research Institute for Health and Medical Professions, Ono Academic College, Israel, and Professor Emeritus, School of Occupational Therapy, Hadassah and Hebrew University, Jerusalem, Israel.

OBJECTIVES. We examined the reliability and validity of the Kettle Test, a brief performance measure based on a complex everyday task designed to tap into basic and higher level cognitive processes.

METHOD. Participants included 21 people attending stroke rehabilitation and 4 occupational therapists for the reliability analysis, 36 people at discharge from stroke rehabilitation, and 36 age-matched healthy control participants for the validity analyses. Instruments included a battery of conventional cognitive measures and functional outcomes.

RESULTS. Interrater reliability was found to be high. Stroke survivors at discharge from rehabilitation were found to require significantly more assistance on the Kettle Test than control participants (p < .000); their scores on the Kettle Test were significantly and moderately correlated with the conventional cognitive and functional outcome measures.

CONCLUSIONS. The results support the reliability and validity of the Kettle Test as a top-down measure of cognition-in-function in people at discharge from stroke rehabilitation.

Hartman-Maeir, A., Harel, H., & Katz, N. (2009). Kettle Test—A brief measure of cognitive functional performance: Reliability and validity in stroke rehabilitation. American Journal of Occupational Therapy, 64, 592–599.

Adina Hartman-Maeir, Hagit Harel, Noomi Katz

People�with�acquired�brain�injury�are�at�high�risk�for�cognitive�impairments�that�have�a�detrimental�impact�on�occupational�performance�(Cicerone�et�al.,�2005;�

Donnovan�et�al.,�2008;�Hershkovitz�&�Brill,�2007;�Zinn�et�al.,�2004).�Occupational�therapy�has�developed� a�unique�body�of�knowledge� regarding� the� relationship�between�cognition�and�occupation� involving�occupation-based,� client-centered�intervention� (Gillen,� 2009;�Katz,� 2005).�Conventional� “tabletop”�measures� of�cognition�are�valuable�diagnostically�but�have�limited�ecological�validity�and�do�not�fully�address�the�functional�implications�of�cognitive�deficits.�Moreover,�the�interdisciplinary�rehabilitation�community�has�emphasized�the�need�for�ecologi-cally�valid�measures�of�cognition�in�function�(Burgess�et�al.,�2006).�This�current�emphasis�is�an�important�milestone�in�the�conceptualization�of�measurement�in�health-related�professions.�Instruments�that�follow�these�directives�are�essential�and�are� integral� to� the� occupational� therapy� philosophy� and� practice� (American�Occupational�Therapy�Association,�2008).�Occupational�therapy�is�in�a�unique�position�to�fulfill�a�central�role�in�this�development�and�is�establishing�its�expertise�in�the�development�of�top-down�assessments�(Hartman-Maeir,�Katz,�&�Baum,�2009;�Law,�Baum,�&�Dunn,�2005).

Evaluation�of�outcomes�in�stroke�rehabilitation,�beyond�basic�activities�of�daily�living�(BADLs),�has�become�extremely�important�as�more�people�survive�stroke�and�return�to�their�homes�in�the�community.�One�primary�concern�at�discharge�from�rehabilitation�is�predicting�the�ability�to�function�independently�in�the�community�or�the�degree�of�assistance�required�to�do�so.�Instrumental�activities�of�daily�living�

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The American Journal of Occupational Therapy� 593

(IADLs)�are�more�complex�than�BADLs�and�thus�require�basic�and�higher-level�cognitive�functions�such�as�executive�functioning�(Cahn-Weiner�et�al.,�2007;�Coster,�Haley,�Jette,�Tao,�&�Seibens,� 2007;�MacNeill�&�Lichtenberg,� 1997).�Thus,�to�address�this�important�outcome�during�stroke�reha-bilitation,�occupational�therapists�have�a�need�for�top-down,�performance-based�assessments�that�will�incorporate�the�cog-nitive�complexity� involved� in� IADLs.�A� small�number�of�performance-based�measures�in�occupational�therapy�fulfill�these�requirements�and�incorporate�cognitive�challenges�in�functional� IADL� contexts;� these� measures� include� the�Cognitive� Performance� Test� (CPT;� Burns,� 2006),� the�Assessment� of� Motor� and� Process� Skill� (AMPS;� Fisher,�2006a,�2006b),� and� the�Executive�Function�Performance�Test� (EFPT;�Baum,�Morrison,�Hahn,�&�Edwards,�2003;�Baum�et� al.,� 2008).�These� instruments� are� valuable� top-down�measures�that�address�cognitive�and�process�skills�in�IADLs.�The�CPT�and�EFPT�each�have�four�or�five�IADL�tasks�that�provide�a�wide�range�of�activities�in�this�domain.�The� scores� on� the�CPT�measure� the� six� cognitive� levels�according� to� the� Cognitive� Disabilities� Model� (Allen,�Earhart,�&�Blue,�1992;�Levy�&�Burns,�2005),�and�the�scores�of� the�EFPT�measure� executive� functioning�components.�The�AMPS�is�an�extensively�researched,�reliable,�and�valid�measure�of�motor�and�process�skills�in�IADLs;�however,�it�requires�intensive�and�expensive�training,�which�is�not�avail-able�for�all�occupational�therapists.

The�focus�of�this�study�is�on�the�development�of�the�Kettle�Test�(Hartman-Maeir,�Armon,�&�Katz,�2005),�a�brief�performance�measure�that�is�based�on�a�complex�everyday�task�and�is�designed�to�tap�into�basic�and�higher-level�cogni-tive�processes.�The�aim�of�the�test�is�to�evaluate�the�ability�for�independent�community�living�of�people�with�identified�or�suspected�cognitive�disabilities.

Development of the Kettle TestThe�Kettle�Test�(Hartman-Maeir�et�al.,�2005)�was�developed�to�provide�a�brief�performance-based�assessment�of�an�IADL�task�that�can�be�conducted�in�a�clinical�setting�or�at�home.�The�test�was�designed�to�tap�into�a�broad�range�of�cognitive�skills�within�a�functional�context�to�assist�in�the�clinical�deci-sion-making�process�regarding�the�need�for�assistance�in�daily�living�skills�of�adults�with�suspected�cognitive�disabilities.�The� basic� task� of� preparing� a� hot� beverage� was� chosen�because�of� its� functional� significance,�broad� cultural� rele-vance,�and�feasibility�(in�terms�of� tools�and�time�require-ments)� in�multiple� settings� (e.g.,� clinic,�home).�The� task�complexity�was�elevated�to�enable�the�assessment�of�basic�and�higher-level�cognitive–functional�skills�that�are�required�for�IADLs,�with�the�following�elaborations:

1.� The�essential�task�of�preparing�oneself�a�hot�beverage�was�expanded�to�include�preparing�an�additional�cup�of�hot�beverage�for�the�therapist;�the�additional�cup�differs�in� two� ingredients� from� that� requested�by� the� client,�providing�additional�load�on�working�memory.

2.� The�electric�kettle�is�emptied�and�disassembled�(lid�and�electric� cable� are�disconnected� from� the�body�of� the�kettle)� to� challenge�problem-solving� skills� and� safety�judgment�regarding�the�use�of�electricity.

3.� Additional�kitchen�utensils�and�ingredients�are�placed�in�the�immediate�task�environment�(on�a�tray)�as�dis-tracters�to�increase�attention�demands.This�design�creates�a�brief�task�using�familiar�objects�and�

settings�that�are�presented�in�a�manner�that�targets�cognitive�skills�underlying�complex�ADLs.�The�observation�is�struc-tured�so�that�the�rater�is�required�to�score�the�performance�on�13�discrete�steps�of�the�task�(e.g.,�turning�on�the�faucet,�filling�the�kettle�with�2�cups�of�water).�Clear�guidelines�for�cueing�are�provided,�and�the�rater�scores�each�step�according�to�the�degree�of�cueing�that�was�necessary�to�complete�the�step�(0�through�4).�Total�scores�range�from�0�to�52�(higher�scores�indicate�more�assistance)�and�can�be�transformed�to�clinically�meaningful�categories�of�independence�on�the�task�(independent,�mild�assistance,�considerable�assistance).

Initial�research�to�examine�convergent�and�ecological�validity�was�conducted�on�the�Kettle�Test�in�a�sample�of�41�elderly� clients� (mean� age� =� 75.2)� referred� to� a� geriatric�assessment�clinic�because�of�suspected�cognitive�disabilities�(Hartman-Maeir,�Katz,�&�Armon,�2004).�Small�to�moder-ate�significant�correlations�were�found�between�Kettle�Test�scores�with�conventional�measures�of�cognition�(r�=�.56�with�Mini-Mental� Status� Evaluation� [MMSE;� Folstein� &�Folstein,�1975];�r�=�.59�with�Clock�Drawing�Test�[CDT;�Freedman�et�al.,�1994];�and�r�=�.32�with�the�visual�attention�Star�Cancellation�subtest�of�the�Behavioral�Inattention�Test�[BIT;�Wilson,�Cockburn,�&�Halligan,�1987),�and�moderate�correlations�were�found�with�caregiver�ratings�of�ADLs�(r�=�.53)�and�IADLs�(r�=�.58).�This�initial�study�provided�sup-port�for�the�validity�of�the�instrument.�Therefore,�the�pur-pose�of�this�study�was�to�further�examine�the�reliability�and�validity�of�the�Kettle�Test�in�a�geriatric�stroke�population�faced�with�similar�concerns�regarding�the�impact�of�cogni-tive� deficits� on� daily� living� abilities� at� discharge� from�rehabilitation.

The�study�was�divided�into�two�stages:�(1)�The�first�consisted�of�the�study�of�interrater�reliability�of�the�Kettle�Test�between�two�sets�of�raters�in�two�rehabilitation�set-tings,�and�(2)�the�second�consisted�of�the�study�of�different�aspects�of�validity�in�a�sample�of�people�at�discharge�from�stroke� rehabilitation� and� healthy� elderly� control� partici-pants.�The�objective�of�the�first�stage�was�to�examine�the�

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594� September/October 2009, Volume 63, Number 5

interrater�reliability�of�the�Kettle�Test�scores�as�administered�by� certified� occupational� therapists� to� stroke� patients� in�rehabilitation.�The�objectives�of�the�second�stage�were�to�examine•� The�construct�validity�of�the�Kettle�Test,�in�terms�of�its�

ability� to� differentiate� between� scores� of� people� after�stroke�at�discharge�from�rehabilitation�and�scores�of�age-matched�healthy�control�participants�who�live�indepen-dently�in�the�community;

•� The�convergent�validity�of� the�Kettle�Test,� calculating�relationships�between�Kettle�Test� scores�with� conven-tional�measures�of�cognition;�and

•� The�ecological�validity�of�the�Kettle�Test,�examining�the�relationship�of�safety�level�and�BADL�status�at�discharge�and�IADL�status�at�home,�1�month�after�discharge

Method

Stage 1: Interrater Reliability Study

Participants�were�recruited�from�two�centrally�located�geri-atric� rehabilitation� hospitals� in� Jerusalem� and� Tel� Aviv.�Inclusion�criteria�required�participants�to�be�admitted�to�a�rehabilitation�hospital�within�1�month�after�stroke,�be�ages�60�or�older,�be�alert�and�without�receptive�aphasia,�and�live�independently�in�the�community�before�stroke.�Twenty-one�patients�consecutively�admitted�to�each�rehabilitation�hos-pital�who�met�inclusion�criteria�participated�in�the�reliability�study�(Hospital�1:�n�=�10;�4�men,�6�women;�mean�age�=�79.3,�standard�deviation�[SD]�=�5.8.�Hospital�2:�n�=�11;�6�men,�5�women;�mean�age�=�77.82,�SD�=�5.1).�The�study�was�approved�by�the�Human�Rights�Helsinki�Committee�of�each�hospital,�and�all�participants�signed�informed�con-sent.�Four�certified�and�experienced�occupational�therapists�(two� in� each�hospital)� rated�patient�performance�on� the�Kettle�Test.�The�test�was�administered�by�one�of�the�raters�while�the�other�observed�the�assessment.�Independent�rat-ings�were�then�conducted�immediately�after�the�assessment.�Interrater�reliability�(Spearman�correlation�coefficient)�was�found�to�be�high�for�the�Kettle�Test�total�scores�for�both�sets�of�raters�(Hospital�1:�r�=.851,�p�=�.001;�Hospital�2:�r�=�.916,�p�=�.000).

Stage 2: Validity Study

Participants. Thirty-six� stroke�patients� (18�with� right�hemisphere�stroke�and�18�with�left�hemisphere�stroke)�were�recruited�from�a�geriatric�rehabilitation�hospital�before�their�discharge� (mean� length�of� stay�=�63.1�days,�SD� =�29.2).�Inclusion�criteria�were�the�same�as�delineated�in�the�reliabil-ity�study.�In�addition,�36�healthy�control�participants�were�recruited�from�a�convenience�sample�of�healthy�elderly�vol-

unteers.�The�inclusion�criteria�for�the�control�participants�were�age�60�or�older,�living�independently�in�the�commu-nity,�and�scoring�>23�on�the�MMSE;�see�Table�1�for�demo-graphic�data).�The�study�was�approved�by�the�Human�Rights�Helsinki�Committee�of� the�hospital,� and� all� participants�signed�informed�consent.

Instruments. A�short�battery�of�conventional�standard-ized�measures�of�cognition�recommended�in�geriatric�stroke�rehabilitation�(Adunsky,�Fleissig,�Levenkrohn,�Arad,�&�Noy,�2002)�was�used�in�this�study.�The�battery�included�the�fol-lowing�measures:•� The�MMSE�is�a�universal�measure�of�cognitive�status�that�

assesses�a�broad�range�of�basic�cognitive�abilities�including�orientation,� attention,� recall,�working�memory,� spatial�abilities,�and�language.�Scores�range�from�0�to�30,�and�scores� >23� are� considered� the� cutoff� for� cognitive�impairment.

•� The�CDT�is�widely�used�in�cognitive�screening�for�many�neurological�conditions�(Freedman�et�al.,�1994).�In�the�stroke�population,�several�scoring�systems�of�a�free-style�drawing�of�a�clock�with�hands�at�10�past�11�have�been�shown�to�have�construct�validity�and�correlate�with�mul-tiple�cognitive�domains,�such�as�abstract�thinking,�execu-tive� functioning,� and� visuospatial� construction� (Suhr,�Grace,�Allen,�Nadler,�&�McKenna,�1998).�In�this�study,�we�used�the�scoring�system�of�Rouleau,�Salmon,�Butters,�Kennedy,�and�McGuire�(1992),�with�a�score�range�from�0�to�10,�which�was�found�to�be�reliable�and�valid�in�stroke�rehabilitation�(Suhr�et�al.,�1998).

•� The�Star�Cancellation� subtest� of� the�BIT�was�used� to�measure� visual� attention,� as� recommended� for� use� in�stroke�rehabilitation�practice�(Edwards�et�al.,�2006).

•� The�Cognitive�scale�of�the�FIM™�(CognFIM;�Granger,�1998)�was�used�as�a�measure�of�cognitive–functional�sta-tus�as�expressed�in�daily�activities�(based�on�general�obser-vation)�in�five�areas�of�cognition�(expressive�and�receptive�language,�problem�solving,�social�interaction,�and�mem-ory).�Each� area� is� rated�on� a�7-point� scale;� total� score�ranges�from�5�to�35.�Reliability�and�validity�have�been�extensively�established�in�the�stroke�population�(Heruti,�Lusky,�&�Dankner,�2002).

•� The� functional� outcome�battery� included� the� areas� of�BADLs,� IADLs,� and� safety—outcomes� necessary� for�independent�community�living.

•� BADLs�were�measured�with�the�Motor�scale�of�the�FIM�(Granger,�1998)�because� it� is� a�universal,� reliable,� and�valid�measure�of�rehabilitation�outcome.�The�FIM�Motor�scale�includes�13�items�of�basic�self-care�rated�on�a�7-point�scale�(total�scale�score�range�=�13–91).

•� IADLs�were�measured�with� the� IADL�scale� (Lawton�&�Brody,�1969;�Lawton,�Moss,�Fulcomer,�&�Kleban,�1982),�

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The American Journal of Occupational Therapy� 595

a�widely�used�measure�for�independence�in�extended�areas�of�ADLs,�including�telephone�use,�shopping,�food�prepara-tion,�housekeeping,�laundry,�transportation,�taking�medica-tion,�and�financial�management�(total�score�range�=�0–23).

•� Safety�was�measured�with�the�Safety�Rating�scale,�which�is�part�of�the�Routine�Task�Inventory�(RTI–E),�a�struc-tured�observation�used� to� rate� cognitive� levels� in�daily�routine�activities�(Allen�et�al.,�1992;�Katz,�2006).�The�4-point�scale�ranges�from�3�(unable to recognize the need for safety precautions)�to�6�(anticipates hazards and plans safety procedures).�The�reliability�and�validity�of�the�RTI–E�has�been� studied� in�populations�with� cognitive�disabilities�(Katz,�2006).

•� The�Fugl-Meyer�Motor�Assessment�(FMA;�Fugl-Meyer,�Jääsko,�Leyman,�Olsson,�&�Steglind,�1975;�Rabadi�&�Rabadi,�2006)�Upper-Extremity�scale�was�used�to�mea-sure�motor�status�to�evaluate�the�possible�confounding�relationship�between�motor� function� after� stroke�with�performance�on�the�Kettle�Test.

Procedure

The� assessment�battery�was� administered�within� the� last�week�before�discharge�from�the�rehabilitation�hospital.�The�Kettle�Test�was� administered�by�Hagit�Harel.�The�other�assessments�were�administered�by�experienced�occupational�therapists�and�rehabilitation�professionals�as�part�of�the�rou-tine�discharge�assessment�battery�of�the�rehabilitation�depart-ment.�In�addition,�to�examine�IADL�status�1�month�after�discharge,�study�group�follow�up�included�a�telephone�inter-

view�administered�to�caregivers.�The�follow-up�assessment�was� completed�on�29�participants,�because�7�participants�could�not�be�reached.�The�Kettle�Test�scores�of�the�7�partici-pants� that� were� lost� to� follow-up� were� not� significantly��different�from�those�of�the�other�participants�(t[34]�=�.892,�p�=�.403)

Data Analysis

Data�were�analyzed�with�SPSS�(Version�15.0;�SPSS,�Inc.,�Chicago).�Descriptive� statistics� and� analysis�of� covariance�(ANCOVA)�were�used�to�examine�the�group�effect�on�the�Kettle�Test�while�controlling�for�years�of�education,�which�were�found�to�differ�significantly�between�groups.�Pearson�correlation�analyses�were�used�to�examine�the�relationships�among�the�cognitive�and�functional�measures�and�motor�and�demographic�variables.�No�significant�differences�were�found�between�participants�with�right-�and�left-hemisphere�stroke�on�the�Kettle�Test�(t[34]�=�0.178,�p�=�.860);�therefore,�the�analyses�were�conducted�on�the�entire�stroke�group.

ResultsBefore�studying�validity,�we�examined�the�relationships�of�the�Kettle�Test�with�demographic�and�motor�variables.�The�correlations�between�the�Kettle�Test�scores�and�age,�years�of�education,�and�FMA�were�all�low�and�nonsignificant�(rs�=�.04,�–.14,�and�–.19,�respectively).�Regarding�gender,�no�sig-nificant�differences�were�found�between�men�and�women�on�the�Kettle�Test�(t�[34]�=�.435,�p�=�.67).

Table 1. Demographic Variables and Performance on the Kettle Test by Group

Stroke Control

Demographics n (%) n (%) Results and Significance

Gender Male 22 (61) 7 (19) χ2(1) = 12.99

p = .000 Female 14 (39) 29 (81)Total 36 (100) 36 (100)

Range M (SD) Range M (SD)

Age (years) Education (years)

60–89 0–19

74.81 (7.32) 10.44 (5.28)

60–84 0–19

72.67 (6.59) 10.44 (5.28)

t(70) = 1.30, ns t(70) = –2.31 p = .02413.10 (4.05)

Kettle Test scoresTotal scorea 1–29 9.34 (5.79) 0–3 0.42 (0.91) F (1,60)b = 63.53

p = .000

Assistance level n (%) n (%)

Independent 5 (17) 35 (97) χ2(3) = 43.53 and 3.53t = .000Mild assistance 13 (45) 1 (3)

Considerable assistance 11 (38) 0 (0)

Note. m = mean; SD = standard deviation; ns = not significant.aHigher scores represent more assistance needed.bAnalysis of covariance, controlling for years of education.

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596� September/October 2009, Volume 63, Number 5

Construct Validity

As�seen�in�Table�1,�the�Kettle�Test�scores�of�the�stroke�group�were�significantly�higher�than�those�of�the�control�group,�showing�the�need�for�more�assistance�on�the�test.�ANCOVA,�controlling�for�years�of�education�(because�a�significant�dif-ference�was�found�between�groups�on�this�variable),�demon-strated�a�large�significant�group�effect�on�the�test�(F [1,�60]�=�63.53,�p�=�.000).�The�study�group�showed�a�wide�range�of�performance�on�the�Kettle�Test�(1–29),�whereas�the�control�group� showed� a�narrow� range� (0–3),� and�only�1� control�participant�required�mild�assistance,�demonstrating�a�floor�effect�on�the�test�for�this�group.

Convergent Validity

The�mean�scores�of� the� study�group�on�the�conventional�battery� of� cognitive� measures� are� presented� in� Table� 2.�Results�show�a�wide�range�of�performance�on�all�measures.�The�Kettle�Test,�which�targets�cognitive�abilities�in�a�func-tional�context,�was�found�to�moderately�significantly�corre-late�with�these�conventional�cognitive�measures�(Table�2).�The�correlations�of�the�Kettle�Test�with�the�four�cognitive�measures�ranged�from�.478�to�.659�(all�significant�at�p�<�.01),�the�highest�being�with�the�CognFIM,�which�is�a�measure�based�on�observation�in�ADLs.

Ecological Validity

The�mean�scores�of�the�stroke�group�on�the�functional�out-comes�were�as�follows:�76.09�(SD�=12.19)�on�the�FIM�Motor�scale,�4.94�(SD�=�0.75)�on�the�Safety�Rating�scale,�and�10.70�(SD�=�5.07)�on�the�IADL�scale�at�follow-up.�The�correlations�of� the�Kettle�Test� and� the�other� cognitive�measures�with�these� functional�outcomes� are�presented� in�Table�3.�The�Kettle�Test�scores�were�significantly�correlated�with�all�three�outcome�measures,� FIM�Motor� (r� =� –.759),� Safety� (r� =��–.571),� and� IADL�1�month�after�discharge� at�home� (r�=��–.505).�The�correlations�between�the�other�cognitive�mea-sures� and� functional�outcomes�were� lower,� and�no� single�measure�correlated�significantly�with�all�three�outcomes.

DiscussionThe�findings�of� this� study�provide� initial� support� for� the�reliability�and�validity�of�the�Kettle�Test�in�stroke�rehabilita-tion.�We�demonstrated�that�the�Kettle�Test—a�structured�observation�of�performance�in�a�complex�task—can�be�scored�consistently�among�professional�occupational�therapists.�In�addition,�participants�after�stroke�required�significantly�more�assistance� than� healthy� control� participants,� who� scored�almost�perfectly�on�the�test.�Moreover,�the�test�performance�of�participants�after�stroke�was�not�related�to�their�motor�status� or� educational� background,�but� it�was�moderately�correlated� with� their� conventional� cognitive� test� scores.�Finally,�Kettle�Test� scores�were� found� to�be� significantly�correlated�with�functional�outcomes�at�the�time�of�discharge�from�the�rehabilitation�hospital�and�at�home.

The�results�concerning�interrater�reliability�were�encour-aging,�considering�the�difficulty�of�reliably�assessing�complex�functional�tasks.�This�positive�finding�can�be�attributed�to�the�structured�scoring�scale�of�the�observation�(divided�into�discrete�steps)�and�the�expertise�of�the�raters,�who�were�occu-pational�therapists�trained�in�observations�of�functional�per-formance.�Further� reliability� analysis� is� in�progress�using�videotape� recordings� that�will� enable�comparisons�among�multiple�raters.�Another�aspect�of�reliability�pertaining�to�the�stability� of� performance� (test–retest� reliability)� was� not�deemed�relevant�for�the�test.�Because�the�test�incorporates�an�element�of�novel�everyday�problem�solving,�we�hypothe-sized�that�immediate�learning�would�occur�from�the�expo-sure�to�the�task�and�examiner�cueing.�Thus,�similar�to�other�tests�that�incorporate�novel�problem�solving,�performance�is�not�expected�to�be�identical�in�a�subsequent�immediate�retest�(Wilson,�Alderman,�Burgess,�Emslie,�&�Evans,�1996).

The�construct�validity�of�the�test�was�highly�supported�by�the�significant�differences�that�were�found�between�the�stroke�and�control�groups.�This�group�effect�could�not�be�attributed�to�the�difference�in�education�because�the�effect�

Table 2. Conventional Cognitive Measures: Descriptive Statistics and Pearson Correlation Coefficients With Kettle Test Scores

Cognitive MeasuresMinimum–Maximum M (SD)

r With Kettle Test

Mini-Mental Status Evaluation 15–30 26.11 (3.96) –.478*Clock Drawing Test 2–10 8.16 (1.85) –.566*BIT Star Cancellation subtest 44–54 52.94 (2.33) –.578*FIM Cognitive scale 15–35 30.38 (4.44) –.659*

Note. M = mean; SD = standard deviation; BIT = Behavioral Inattention Test.*p < .01.

Table 3. Pearson Correlation Coefficients of Functional Outcomes With the Kettle Test and Conventional Cognitive Measures

BADLs(FIM Motor

Scale)

Safety Level(RTI Safety

Rating Scale)a

IADLs(IADLs Scale)

Kettle Test –.759** –.571** –.505**Mini-Mental Status Evaluation .261 .122 .401*Clock Drawing Test .365* .112 .182Star Cancellation subtest of BIT .462** .102 .237FIM Cognitive scale .435** .446** .287

Note. BADLs = basic activities of daily living; RTI = Routine Task Inventory; BIT = Behavioral Inattention Test; IADLs = instrumental activities of daily living.aSpearman correlation analysis was performed on this variable because of its ordinal 4-point scale.*p < .05. **p < .01.

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The American Journal of Occupational Therapy� 597

remained�when�controlling�for�years�of�education.�Moreover,�education�was�not�found�to�be�significantly�related�to�per-formance�on�the�Kettle�Test,�and�no�difference�was�found�between�the�performance�of�men�and�women�on�the�test.�Therefore,�the�differences�between�the�groups�support�the�construct�validity�of�the�test�to�differentiate�between�known�groups�with� identified�differences� in� cognitive� functional�status.�We�expected�that�healthy�adults�who�are�living�inde-pendently�in�the�community�would�succeed�on�the�Kettle�Test;� this� expectation�was� indeed� confirmed�by� the�floor�effect�among�the�control�group,�in�which�only�1�participant�needed�mild�assistance�on�the�test.�The�findings�suggest�that�the� test� can�detect� cognitive–functional�deficits� in� adults�with�neurological�dysfunction;�however,�the�test�is�not�sensi-tive�to�possible�variance�in�cognitive–functional�performance�of�normative�healthy�adults.�Further�research�is�required�on�larger,�more�representative�samples�of�different�diagnostic�groups�with�identified�cognitive�disabilities.

The�significant�moderate�correlations�that�were�found�with�conventional�established�measures�of�cognition�support�the�convergent�validity�of�the�Kettle�Test,�demonstrating�the�expected�strength�of�association�(r�=�.50)�between�measures�with�overlap�of�construct�(Gregory,�2000).�The�correlations�with�the�“table-top”�tests�(MMSE,�CDT,�and�Star�Cancella-tion)� suggest� that� common�underlying� cognitive� abilities,�including�attention,�memory,�praxis,�and�executive�functions,�are�being�tapped�by�these�measures.�However,�the�moderate�degree�of�association�supports�the�contention�that�the�Kettle�Test�is�also�tapping�into�additional�aspects�of�performance�not�addressed�by�these�conventional�cognitive�measures.

These�findings�are�similar�to�the�initial�findings�regarding�the�Kettle�Test�in�adults�with�suspected�dementia�(Hartman-Maeir�et�al.,�2004)�and�to�those�of�other�studies�of�top-down�assessments�such�as�the�AMPS�and�the�EFPT,�where�moder-ate�associations�were�found�with�table-top�measures�of�cogni-tion�(Baum�et�al.,�2008;�Fisher,�2006a).�The�significant�cor-relation�that�was�found�between�the�Kettle�Test�scores�and�the�FIM�supports�the�validity�of�the�test�as�a�measure�of�cognition�in� function.�The�FIM�Cognitive� scale�provides� a�valuable�measure�of�functional�cognition�in�stroke�rehabilitation;�how-ever,�it�relies�on�the�day-to-day�observations�of�clinicians�in�the�rehabilitation�setting�and�has�a�high�focus�on�BADLs.�This�setting�does�not�necessarily�provide�an�opportunity�to�observe�the�client� in� the�more�complex� tasks� that� are� essential� for�independent� living� in� the�community�after�discharge.�The�moderate�association�that�was�found�may�shed�light�on�the�possible�unique�contribution�of�a�short�IADL�performance�test,�beyond�a�general�observation�in�daily�life.

The�ecological�validity�of�the�Kettle�Test�was�substan-tially�supported�by�the�significant�correlations�with�all�func-tional�outcomes�(ADLs,�safety,�and�IADLs).�Conversely,�the�

pattern�of�correlations�between�these�outcomes�and�the�con-ventional� cognitive� measures� showed� fewer� and� smaller�effects,�and�no�single�measure�correlated�significantly�with�all�outcomes.�The�outcome�measures�that�were�chosen�for�this�study�represent�functional�areas�that�are�pertinent�issues�for�discharge�planning�after�stroke�and�for�independent�com-munity�living.�The�findings�clearly�support�the�advantage�of�the�Kettle�Test�in�its�relation�to�these�outcomes.

From�our� clinical� experience,� the� ecological� and� face�validity�of�the�Kettle�Test�for�discharge�planning�has�been�shown� to�be�valuable� for� clients� and� their� caregivers.�On�discharge�from�hospital,�the�need�for�assistance�in�ADLs�and�safety�status�is�of�major�concern�in�planning�for�community�living.�Questions� such� as� “Can� I� return�home�alone?”�or�“What�type�of�assistance�will�I�need�to�live�independently�in�the�community?”�are�of�vital�importance.�For�example,�study�participant�A.�R.�is�a�73-year-old�married�man�who�was�liv-ing�independently�in�the�community�before�his�stroke.�He�did�not�have�any�residual�motor�deficits�at�this�stage�of�reha-bilitation�and�was�independent�in�BADLs,�yet�his�conven-tional� cognitive� test� scores� revealed� some�mild�deficits� in�measures�of�clock�drawing�and�visual�attention.�A.�R.’s�per-formance�on�the�Kettle�Test�demonstrated�a�significant�need�for�assistance�on�multiple�steps:�He�was�baffled�by�the�empty�kettle,�had�difficulty�connecting�the�electrical�cord,�and�only�prepared�one�cup�of�beverage�(instead�of�two),�using�cold�water.�The�face�validity�of�this�assessment�for�the�client�and�his�wife�was�useful�in�accepting�the�current�need�for�assis-tance�on�going�home.

Conclusions, Limitations, and Future RecommendationsThe�Kettle�Test� is� a�brief,� cognitive–functional,� top-down�measure�that�assesses�actual�performance�on�a�familiar�IADL�task�with�built-in�complexity.�The�results�of�this�study�support�the�reliability�and�validity�of�this�measure�in�stroke�rehabilita-tion.�The�Kettle�Test�can�be�used�in�diverse�settings;�it�is�short,�easy�to�learn�and�administer,�and�provides�meaningful�infor-mation�pertaining�to�independent�community�living.

The�study�was�limited�by�a�relatively�small�sample�size�that�did�not�enable�multiple�regression�analysis�for�examin-ing�the�unique�prediction�of�the�Kettle�Test�to�the�explained�variance�of�functional�outcomes�beyond�other�conventional�measures�commonly�used�in�geriatric�stroke�rehabilitation.�In�addition,�the�data�regarding�IADLs�were�collected�by�a�telephone� interview�with� caregivers,�which�may�not�have�fully�captured�this�area�of�functioning.�Further�studies�should�include�home�visits� to� confirm�and� replicate� the� current�findings�in�the�geriatric�stroke�population�and�in�other�diag-nostic�groups�with�cognitive�disabilities.� s

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598� September/October 2009, Volume 63, Number 5

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