Cognitive Performance

in Senile Dementia of
the Alzheimer's Type:
The Kitchen Task
Assessment
Carolyn Baum, Dorothy F. Edwards
Key Words: activities of daily living.
Alzheimer's disease

The Kitchen Task Assessment (KTA) is a jimctional

measure that records the level 0/ cognitiue support required hv a person with Senile Dementia 0/ the Alzheimer's Tvpe (SDAT) to complete a cooking task succes_~/ullv. The results allow the clinician to help
caregivers understand the ler'el o/support the impaired person needs to perform dai/]' living tasks This
paper presents the validit) , and internal consistenc)' 0/
the KTA Data were collected from 106 persons diagnosed with 5DAT Construct /jalidity was establisbed by
examining the relationship het/(xen subjects' pel/ormance on tiJe KTA and standard nellropsl'cholo[;ical
measures.

Camlyn I3aum, ,\IA. OlR I FAOl.\. is Elias Michael Director and

Assislanr Professor of Occupalional Therapy and Neurology,
and Direcrol' of the Program in Occupational Therapy at
Washingron Universiry School of Medicine. Box 8066. 4567
Scot I Avenue, Sf. Louis, MiSSOUl'i 63110.
[)orolhv F. Edwards, Phil. is As~islanr Profe~sor of Occupalional Thel';PY and Neurolug:', Washinglon Universil:' School of
Medicine, 51. Louis, Missouri.
Tbis ar/ide

/.('(/S

accepted/or puh/iuilio)l JaJ1ua r r 15. /993

The> AmeriClA1/ Jourl/al

rofessionals studying and trearing persons with de-

menria need to know the capabilities of the person

with Senile Oemenria of rhe Alzheimer's Type
(SOAT) to help rhe caregiver develop strategies for managing his or her family member. It is often difficult to
determine rhe residual capahility from self or family reports. Traditionally, neuropsychological tcsts (specifically, measmes of brain function) are used to predict behavioral pattcrns. These tests are important in diagnostics as
rhey can he used to gUiue clinical and hehavioral management programs and to prOVide information about deficiencies of language, memory, perceprion, reasoning,
planning, emotion. and self-control (Wilson, 1987). However, critics have caurioned againsr roral reliance on specific neuropsychological tesrs ~lS predicrors of funcrionaJ
srafUS because a person's poor performance could be due
to an inabilirv to integrate visual, moror, anu cognirive
skills (Elithorn, 196-'); Hearon & Pendleron, 1981). Lirrle is
known abour rhe relarionship bcr\veen :1 [lcrson's performance on ncuropsvcho!ogical tests and his or her performance of cveryday activiries (\X!ilson, 1987). Neuropsychological resring does nor prcwide information abour rhe
abilitv of the per-son wirh SOAT to pCt'form a rask or the
level of assisrance necess3l'y ro supporr him or her in rhe
performance of rhe rask.
The occuparional therapisr evaluates cognirion ro
derel-minc wherher a person can use rhinking and memor\' skilLs fCl fZlciliwre performance of daily life rasks (Reed,
1984). Ir is imrorranr ro understand a person's strengths
in order ro bvpass the weaknesses resulting from the
demenria (Wilson, 1987). Ir is also imporrant to have an
assessmenr rhm records change in the pel'fot'l11anCe over
rime because the person's performance changes as rhe
disease progresses. The Kirchen Task Asscssmenr (KIA)
was developed to provide a performance-based standardi/ed assessment.
In 1983, when the KTA was developed, no standardized perforrr18nce-based cognitive measures exisreu: two
assessmenrs were developed suhsequently for occuparional rheraliists' use The Allen Cognitive LeveJ (ACL) resr
is a screening rool thZlr iclenrifies a person 's por~nrial for
rehabilitation (Allen, 1991). 1t measul'es "a quality of
problem solVing used while doing a perceptual moror
task" (1991, p. 2). Ol"iginally designed for psychiarric patients, rhe ACL is now used [0 test persons wirh Other
diJgnoses. The scoring uiteria desuibc rhe motor beh:1vior of a person performing a learher lacing task. Though
similar to rhe ACL. as it involves the perfol'lllance of a
task, rhe KTA diffCt's in thar rhe examiner elicits and rccOl'ds rhe highesr level of performance with cues and
as.,;isrance.
The orher instrumenr dcveloped since 1983 is rhe
Assessment of Morm and Process Skills (AJ\tlPS) (Fisher,
1991) The !\ivlPS measures skills such as posture, mobility, coordin:1fion, and strengrh, as well as attenrional, ideational. organizational, and adaptive capabiliries. The

ur OcclipatioJ1o/ Thel'upr

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431

KTA differs from the AMPS in that it measures onlv the

actions associated with the processing skills of initiation,
organization, inclusion of all steps, sequencing, safety and
judgement, and comrletion and was designed only to
measure the cognitive aspects of performance.
The KTA (a) evaluates the cognitive rrocesses that
affect task rerformance and records the level of cognitive
surport necessary for successful task completion; (b) can
be performed either in a clinic or in the person's horne in
a short reriud uf time; (c) alluws the clinician to observe
and translate the person's performance into strategies
the caregiver may use to manage the cognitively impaired
person un other activities of daily living and instrumental
tasks; and (d) generates a score to measure changes in
performance over time (either progression or improvement). It can be used with a companion instrument, the
Functional Behavior Profile (Baum, Edwards, & MorrowHowell, in rress), to record the caregiver's rerceptiun's
of the impaired person's capahilities. This paper presents
a study exam ining the content validity and construct validity, interrater reliability, and the internal consistency of
the KTA

Method
Subjects
The subjects in this study came from the Memory and
Aging Project at Washington University, a longitudinal
study of healthy aging and SDAT The subjects were recruited through public annuuncements, the Alzheimer's
Disease and Related Disorders Association, and referrals
from community physicians and uther health professionals. Before enrollment in the Memory and Aging Project,
rotential subjects were tested for hypothyroidism, vitamin B-12 deficiency, and uther potentially reversible
causes of dementia. Thuse with severe h)'pertension,
strokes, severe medical problems, or psychiatric illness
were excluded from partiCipation. This study included
106 suhjects, 56 women and 50 men with a mean age of
71.75 years (range 53.8-85.4). Ninety-three rersons were
married; 13 were widowed or single. All were living in the
community with a caregiver.
Diagnosis and staging were performed hy a team of
neurologists and psychiatrists using the Clinical Dementia Rating [CDRj (Berg, 1988; Burke et aL, 1988). This
alluws the analysis of data across the progressive stages of
the disease. A CDR is derived from the subjeCts' performance in the areas of memory, orientation, judgment and
prohlem solVing, community affairs, home and hohbies,
and personal care. Clinical Dementia Ratings of 0.5,1,2,
and 3 indicate questionable, mild, moderate, and severe
dementia.

Instruments
The KTA tests the cognitively impaired person's ability to
complete the task of making cooked pudding from a

commercial package. The test addresses the follOWing

questions regarding the person's performance:

1 Can the person begin the task?

2. Can the person gather the items necessary to
perform the task?
3. Can the person rerform all the steps necessal)' to
complete the task)
4. Can the person sequence the activiti<:s that make
it rossihle to complete the task?
5. Is the person safe in performing the task)
6. Does the person know when he or she is finished
with the task?
The person administering the test provides the necessary assistance to make it a successful exrerience for
the subject (see Appendix A) Performance is scored on
the follOWing components: (a) initiation, (b) organization, (c) rerformance of all steps, (d) sequencing, (e)
judgment and safety, and (f) cumpletion. The level uf
surport required from the tester fur each component is
scored: 0 (independently competent), 1 (reqUired verbal
cue), 2 (reqUired physical assistance), 3 (totally incapable). The higher the score, the more impaired the perfurmance (total scores range from 0 tu 18) (see Appendix
B).

Procedure
The KTA (see Figure 1) was administered in the occurational therapy department kitchen as a part of a Functional Test Battery by an occupational therapist or research
assistant trained in its administratiun. The caregiver was
not present, and the testers were blind to the CDR rating.
Testers recurded observations regarding the assistance
the)' provided during the assessment but the scming was
recorded only after the task was finished. Verbal assistance and physical assistance were marked regardless of
the numher of cues given. The subject may have needed
several verbal cues and only one physical assistance, but if
physical assistance was required, it was recorded.
Five analyses were used in this study: (a) Kendall's
tau B to determine the interrater reliability of the KTA; (b)
correlation analysis to examine the relationship among
the six variables in the measure; (c) factor analysis to
identify common relationships among the variahles; (d)
correlation analysis with other valid instruments to determine the construct validity of the KTA; and (e) analysis of
variance to examine the KTA across stages of SDAT and
between men and women.

Results
For the Kendall's tau B analysis, Videotapes of three subjeCts, each at a different stage of impairment, were scored
by 12 persons. The testers were given an orientation to
the KTA and a descriptiun of the scoring criteria. They

432
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,11(/1'

1993, vutume 47. Number 5

'.JAME

DATE

EXAMINEI~

Circle the number that corresponds to the level of support the individual required_

COMPONENT

REQUIRED
PI IYSICAL
ASSISTANCE

NOT
CAPAI3LE

.J

.3

.3

.3

.3

INDEPENDENT

REQIIIRED
VERl3AI. CUES

INITiATION:
DID HE OR SHE I3EGf I TilE
TASK WHEN ASKED TO I3EGIN'

ORGANIZATION:

Oil) HE OR SHE GATHER THE

~ECF.SSARY

ITEMS. TOOLS,
INGRP:OIENTS, ETC.
TO DO TIlE .10m

PERFORM:S ALL STEPS:

DID III' OR SHE DO
EVERTIIING TIIAT WAS
NECESSARY TO COMPI.ETE
THE TASK'

SEQUENCING:
DlD HE OR SIIE DO EVERYHING
IN TilE ORDER THAT MADE
SENSE, GIVE THAT TASK'

JUDGMENT AND SAFETY:

WAS HE OR SI IE SAFE AND
AWARE OF POTENTIAL
DANGERS'

COMPLETION:
DID HE OR SHE RECOGNII.E
THAT THE TASK
WAS f'INISHED'

Figure 1. The Kitchen Task Assessment.

were then shown the videotapes and asked to score 3

subjects. There was no discussion until all three subjects
had been scored. The interrater reliahility for the total
score was .853. The range was .632 for safety to 1.0 for
initiation.
As a preliminary step to the correlation and factor
analyses, the univariatcs were reviewed for the total subject group (n = 106) and the four CDR groups. Scores on
the KIA increased with the severity of dementia (see
Table 1). The CDR 3 group were the most impaired. The
tremendous variahility within each CDH group should be
carefully noted. The importance of staging SDAT persons
when conducting research is demonstrated by the performance of the group as a whole. The mean score of8.71
suggests that a1l106 suhjects would require physical assistance with the task. When subjects are grouped by CDR
stage, the mean scores of th<:: ljuestionahle and mild
grou ps (1.75 and 4.65 respectively) clearly indicate that

these subjects required only verbal assistance on the KTA.

For the correlation analysis, correlation coefficients
were computed among the six KTA variables and the total
score (see Tahle 2). The strong correlation coefficients of
.72-.84 suggested that only one dimension might exist
(Nunnally, 1978) and that the sample of cognitive domains selected for the KTA all contrihute to the measurement of the cognitive performance of the task.

Table 1
Mean, Standard Deviation and Range of Scores on the
Kitchen Task Assessment by Stage of Dementia
CDR O.S

CDH I
CDI{ 2
Cf)I(

7be American journal oj' Occupational Tberapl'

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.~

(QUte'li()(1;lbk)
(Mild)
(Modcralte)
(Sc\,terte)
('1'< H;11 SUbjl'lIS)

-i2
21

/.7S
-1.6S

0-07
O-IK

9~1

4-1~

10

I:~.~H

7-IH

~.71

a-It-:

55

10(,

433

ation and sequenCing, The subject is required to draw

vertical lines through a series of horizontal lines, The test
is scored so that the higher the score, the better the
rel'formance

Table 2
Pearson Correlation Coefficients Among Test Items
(n = 106)
Inilialion
Initialion
Organ il,al il)n
Include All
Stcps
Sequencing
Safc!)'/1 udgmeJ)(
Completion
TOldl KTA

O'gan-

All

il.<Hion

Sleps

Sequcncing

SaFcl)'

Compk:!ion Total

Functional Tests

10
,K2
7K

10

,77

.K2
K6

ID
K9

,72

,77

,7)

79
92

.HI
H,3
9j

.HH

ID
Hl
,H2

ID
H)

94

90

ID
9.3

10

Nule, None oFllle correlali'"1 c()(:mcicflls was helo'" .72 (P = <.00(1)

Factor analysis was used to explore the component

structure of the variables, A principal component analysis
was computed to determine the internal structure of the
variables and to establish the KTA as a unidimensional
instrument, A varimax rotation was chosen to reveal the
relationship among the variables. The orthogonal rotation resulted in the identification of only one factor accounting for 84% of the variance. All the factor loadings
exceeded ,88,
In the fourth analysis, construct validity, the KTA was
correlated with established valid and reliable neuropsychological and functional tests,

Neuropsychological Tests
Token Test Short Version This tcst (De Renzi & Vignolo, 1968) consists of six parts. It measures verbal pro
cessing and is sensitive to disru pted linguistic processing,
The subject must comprehend the token names and the
instructions and be able to pick the correct response and
take (a motor response) the token from the table, Parts 1
through 4 are progressively more difficult because of the
number of tasks that must be performed in sequence,
The process reqUires the subject to follow a series of
commands. Perseveration (inability to move to another
task) is often seen as the instructions become more complex, If the person fails to respond in 5 seconds, the
instructions are repeated; a half score is recorded for the
second try, Thus, the test contains aspects of initiation
and sequencing. The test is scored so that the higher the
score, the better the performance.
Trail Making Test-Part A (Armitage, 1946) is a
timed test of visual conceptual and visuomotor tracking
and involves motor and attention skills. The subject must
connect numbered circles on a page, a task that involves
initiation and sequenCing, The test is scored so that the
higher the score, the poorer the performance,
Crossing Off Developed by Botwinick and Storandt
(1973), this is a timed test of psychomotor speed functions, without a verbal component, that measures initi-

Clinical Dementia Rating [CDR). This test (Hughes

et aI., 1982; Berg et aI., 1982) is a measure of a person's
performance in daily living tasks in the areas of memory,
orientation, judgment and problem solVing, community
affairs, home and hobbies, and personal care as given by
caregiver report, The test indicates severity of dementia
and rrovides a picture of the overall performance of the
subject. The test is scored so that the higher the score,
the poorer the performance.
Blessed Dementia Scale. Developed by Blessed,
Tomlinson, and Roth (1968), this is a behavioral check list
derived exclusively from questions asked of the caregiver;
it rates the subject on performance of everyday activities,
changes in personal care, and changes in personality,
interests, and drive, This test was included to see how the
subjects' actual performance as reported by the KTA related to the performance reponed by the caregiver. The test
is scored so that the higher the score, the poorer the
performance, The cognitive section of the Blessed Dementia Scale was analyzed separately.
The correlation coefficients of the neuropsychological and functional tests are shown in Table 3, The more
complex integrative tasks (Token test 2, 3, 4, 5, and 6)
were more highly correlated than the Crossing-Off and
Token Test 1. The CDR and the Blessed were Significant
Table 3
Correlation Coefficients of Neuropsychological
Measures with the Kitchen Task Assessment (n = 106)
lnilalion

Te'l
Token Tesl
Pan J
Tokcn '1'<:"
Pan 2
Tokcn '1'<:,'1
Pan :\
Tokcn Te.'t
P:1rI .j
Token Test
Pan ')
Token TeSI
Pan 6
T'i:d Making
A (sc-c)
CDr<
Cn >s,'ing-OFF
J3k"ed
Delllcnli;,
Bksscd Dc-

- :IV - AW""

COin

Towl

i/,atioll 1I1i ence

Safely

pbion

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SICP,

I''''''

.2H

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,:\4':'

- .44':':' - AT':'

.)9':"" - ,67':'" - .S9':"' - ,62':':' - ,e,j"":'

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Cognitive

':p> 00]
';':-P> ,0001

434
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",fa)! 1993, Volume 47, Number 5

at the p >0001 level hut wel-e not rerfeetly correlated.

One possible explanation for the less than perFect correlation with the Functional measures may he that the caregiver reporting on the person with SDA1"s perFormance
may not be capahle of cueing the suhJect to achieve the
level of performance obtained hy the trained examiner
The highly significant correlations with the rsychometric
measures served to establish construct vaJiclity of the
KTA The KTA, as a test of practical cognitive skills, is
related to the cognitive skills measured by neuropsychological tests.
The coefficient alrh8 sets an urper limit to the internal consistency of a test and provides a good estimate of
reliability (Nunnally, 1978) The Cronhach Alpha For standardized variables was 961. The coefficient :Jlrha of the
KTA by CDR group was .1175 for CDR 05,909 for CDR 1,
944 fm CDR 2, and 963 for CDR 5 The high reliability
coefficients suPPOrt the structure of the test.
The fifth analysis, analysis of variance, examineel the
differences on the KTA across the stage.s of SDAT ancl
yielded a significant Fratio of 3723 (df = 4.102; P <
.000l). This demonstrates that performance on the KTA
\,vas afFected by the progression of the disease. POSt hoc
Scheffe tests (see Table 4) on the means demonstrated
significalll differences for all stages of the disease Because [here could he a question of gender bias in the
selected task, Table 4 also reports the perFormance of
subjects in CDR grours hy gendel. There is a difference
between the scores of male and female suhJects in the
questionahle (CDR = o =i) and moderate (CDR = 2)
stages of the disease.
Perhars men in the question3ble stage of the disease
(CDR = 0 ')) rerformed berter beca use they read and
followed the dil-ections, whereas women in this gmur,
who may h3ve been more familiar' with the task of cooking, were less likely to refer to instruerions. ]n the moderate stage (CDR = 2) INomen may have rerformed berter
because they relied on over-learned skills Regardless of
gender, [he KTA differentiates performance across all
stages of [he disease.

Discussion

the clinician to administer a .stand3rdil.ed measure without employing an anificial task. The KTA is a valid and
reliahle measul-e that C8n be used as a clinical as well as a
research [001 because it c1isCi"iminates the performance of
persons across all stages of the disease; therefore, it can
record ch3nge.s in the rerson"s rerFormance
The inform3tion obtained from the admlllistration of
the KTA will be helpFul in obtaining objective information
that the clinician can use in training the caregiver to assist
the person with SDAT in daily living tasks. The mean
score oFthose in the mild stage of the disease (CDR = 1)
indicates that verbal cueing is necessary to surr0rt performance; those in the moderate and severe stages oFthe
disease (CDR = 2 and CDR = 3) require rhysical assistance However, the variation demonstrated by the subjeers in the t3sk indiccltes that knowledge of the diagnosis
and the stage oFthe disease does not rerFectly prediCt the
I)erson"s carabilities. Individual assessment is necessary
to cletermine the aCtual functional capabilities of the person with SDAT Some ofrhe variahility in the performance
of subjects in the questionahle and mild SDAT groups
may be attrihuted to their unfamiliarity with the testing
environment. A sludy to test the instrument's ecological
validity in the home and cliniC setting is needed
The health care team will henefit from knowing
whether or not a person with SDAT can perform a complex basic living t,lsk independently and the level of cognitive support necessary for successful t3sk comrletion.
The infomlation fmm the KTA can assist the te3m in
disch8rge planning and counseling a family on the level of
interaerion necessary to support a cognitively impaired
person in the community This standardization of [he
KTA was on a selected sumple of persons with SDAT For
u~e with other' [)opubtioI1s, the validity of the test with
that l)opulation must be established fir'st. A
Acknowledgments
We thank Lconard Berg, .'111. Director of rhe AJzhellYler's Disease
RcscJrch Ccntcr, Jnfl David Cillesrie, PhD George Warren
Brown School of Social Work;ll Washingron llnlversiry, for rheir
rhoughrful r-evielVs of this pJper
This wmk \\8S supponccl in p,lr( hy rhe National Inslilure on Aging. Granr #A6()399 1 ami The Norman J SlUpp
Foundation

The Kitchen Task Nisessmelll was designed to gUicie the

occupation31 therapisl in treatment planning It allows

Table 4
Means of KTA Scores across the stages of SOAT for
Females, Males, and All Subjects

Appendix A
Administration Procedure
PIT-resr Ser-up

(:I)!{ () ~

(li Lll"lillll'
1/

,,11k)

f-l'lll;t1C ~c()rc

~(,

~.{)ll"

;\-lale ,u>re

'iO

TIll:l! :-'Cllre

W(,

Ir
I '(,.

(1)1'

CJ)R

CJ)R"

(Illild)

(ll11ld.)

(",('\erc)

-15"

HH5'
II 11';
<) I >it.

15 He-,

l.

'196
-J.6~~

'\ ,A
I,-I.HW

.:'p = <{)'i

The American Journal or Occupational Therapy

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Place to Ihe lefr on the ["()UIHer

201 :3 fLiI'lllS of I)ullding mix ([he kind Ihar require, couking. nor insral1r)
a 1-11., lju:nr saucel,an wirh a heal-rc.sislanr handle
:1 11()(lden .'iI)(1Lln
a ru hhe r sera pc r
a 2 Clip glass mC~lsuring cup
.j sm:lll dishes (paper CLIpS will do)

435

to rhe subjecr< needs CJive phvsical assistance if

the person is in danger.

2. Have a quarr of milk in [he ,efrigeraror

:3. PIint rhe instructions in large letters on a riece of papn and

mount the instructions where the person can read [hem. Use
the same instruerions that are on the box, except add "pour
inro curs."
4. Have hand soap and raper towels near Ihe sink.
Before you begin the assessment:
Determine the individual with SDATs ability to rTspond to
verbal or rhysical assistance or- both by instruering him or her to
wash his or her hands. If the person can not do this, eithn with
or without assistance, the tesr should not be adminisrered, as
the rerson will not be able to follow cues and will be unsuccessful.
Instructions
Tell the person
ro mix a box of pudding and rour the mixrure into four
dishes
that the milk is in rhe refrigerarorhow the srove works and whar burner ro use
that the instruerions are on the box and on the wall
to begin when readv
You will cue only after you have determined he or she
cannot perform without heir (wait five seulIlds) UN
LESS safety is an issue.

Appendix B
Scoring Guide
Initiation:

Did he or she begin the task after being told to

begin~ If not, did he or she begin when reminded (verbal) or did you have to oren the box and
hand it to him or her (rhysical)'

Organization: Was he or she able to get the milk from the refrigerator and use the tools arrrorriatelv~ Some
may use the rools or equirlllent incorreerly; for
examrle, some t1y to cook in the measuring cur.
Did the rerson resrond to verhal help or did he
or she requir-e rhysical assistance~
Perfor-mance Did he or she relfor-m all the major steps - meaof all steps: suring, stirring, pouring - a/()ne~ Diel you have
to assist him or her, for examrle, light the stove?
Was it verhal or rhysical assistance?
Sequencing:

Judgment
and Safety:

Was he or she able to do the tasks in a funerional

sequence? During sequencing, it is essential not
to overcue. Some reor1e stir the mixture initially
in the cur. This is permissihle if he or she has
the right amount of milk and all of the mix from
the hox. Some peorle pour the hot mixture into
the measuring cur before filling the serving
dishes. This, too, is rermissible. A problem
arises when the person does not perform the
tasks necessary to rroceed with the activity, i.e.,
rour milk or powder into the dishes, or turn on
the stove hefore starring.
Evaluation is hased on how the rerson manages
the stove and the hot pudding. Because of the
possihility of injury, tbe examiner must he alen

Conlpletion. Evaluarion h ha.'ied on whether the person knows

he or she is finished Some will continue rhe
proccss and do chores such as scraping the pan
after it is empty or moving the dishes around on
the counter. Jic or she may put the dishes in the
sink, hut is nO[ required to clean ur. Saying that
vou will wash the dishes is nO[ consiclel-cd a
~erhal cue; howevcr, you must wait until he or
she puts the rudding in the dishes before you
offer to clean ur

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iVlav 1993, Volume 47, Number 5