1.1 Introduction

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This chapter consists of the background of the study to explore more about the topic of study based on existing literature, problem statement that provides a brief description of the issues that want to be identified. Besides that, this chapter also explains the significance of the study to guide during research conduct and which the findings will be useful to others. Lastly, this chapter also provides the research objectives, research question, and the hypothesis of the study.?
1.2 Background

These days, an ageing population is one of the issues being discussed by many people. Gavrilov and Heuveline (2003) describe the term of population ageing as the age of population distribution were shifted toward old ages. Ageing of the population occurs when the middle age of country increases and shifts the distribution of the country’s population towards older ages which is a global phenomenon experienced not only in developed countries, but also in less-developed countries (Tobi, Fathi, ; Amaratunga, 2017). They also stated that the number of older people in Malaysia is increasing rapidly. World Health Organization (WHO, 2010) defined the elderly person as an individual aged 60 and older.
The number of population aged 60 is growing rapidly than other younger age groups and expected to increase every year. By the 21st century, it is predicted that this population’s demographic trends will be among the most prominent. The data from United Nations Department of Economic and Social Affairs (UNDESA) in 2017 shows the number of elderly persons (aged 60 or above) is predicted to grow and more than double by 2050 (2.1 billion) compared to 2017 (962 million) and more than triple by 2100 (3.1 billion). Malaysia also is now facing the same situation as another country where the statistic had shown a rapidly increasing number of elderly. In 2010, Malaysia’s ageing population reached 28.3 million and within the following 30 years expected to grow to 38.6 million (Tobi et al., 2017). The increasing number of older people have good and bad consequences. Hamid (2015) stated the increasing number of older people in the world is a success because people’s life expectancy is longer due to enhanced living conditions and higher quality of health care. However, the large proportion of elderly people with their uncommon old age also a challenge because the society has never experienced it.

The elderly people encountered both normal and pathologic of physical and psychological changes as they aged. The issues related to ageing which the rising number of disability including cognitive impairment is one of the problems that needs to solve. Ageing can cause the efficiency of physiological function is reduce and increase the risk factor of many diseases due to the general condition of deterioration of many organs and systems (Albert, Im, & Raveis, 2002). These changes clearly may cause interference with their daily life activity. The ageing population will cause the number of people with disability tremendously increase as the rates of disability increase with age (Smith, Rayer, & Smith, 2008). Cognitive impairment is one of the common age-related condition issues and it is a common problem amongst older person because of the ageing process. The cognitive impairment and dementia are described in which the most functional independence, cognitive abilities, and social relationships are declined progressively and devastating (Peracino & Pecorelli, 2016).

According to Harada, Natelson Love, and Triebel (2013), the deteriorations in certain cognitive abilities, for example, executive function abilities, processing speed and certain memory, language, and visuospatial are related to the process of normal ageing. Executive function skill is important throughout the life because it allows people to plan, organize and complete everyday jobs where the past experience relates to present action by a set of mental processes. Executive functions are controlled by the prefrontal area in frontal lobes of the brain. Elliott (2003) defined the term of executive function as a complex cognitive processing where there are several subprocesses need to coordinate to accomplish the goal. Declining in executive function is a common issue faced by elderly people. It often leads to many difficulties such as organizing, planning and initiation, and processing, storing or retrieving information.

As our population grows older, the screening of early detection of cognitive impairment for older people is extremely needed. This screening is important to detect the illness at an early stage as there is a rapidly increasing number of people with dementia will become a challenge to society. Kim et al. (2017) state that early detection of cognitive impairment would enable early treatment that probably more effective. There are many assessments that can assess cognitive impairment in older people such as Mini-Mental State Examination (MMSE), Rowland Universal Dementia Assessment Scale (RUDAS) and Lowenstein Occupational Therapy Cognitive Assessment- Geriatric (LOTCA-G). However, there is still a lack of assessment that assesses the performance of the executive function in older people. The example of a performance-based assessment that can screen the executive function is Executive Function Performance Test (EFPT), Executive Secretarial Task but these assessment takes a longer time to complete all subtest. Thus, the Kettle Test which is also performance-based assessment is used in conjunction which can be assessed in many different cognitive areas (including memory, executive functions) in a shorter time. The Kettle Test was developed by A. Hartman-Maeir, Armon, and Katz in 2005. Hartman-Maeir, Harel, and Katz (2009) stated this assessment was designed to evaluate many cognitive skills to help in the clinical decision-making process within the purposeful context for those adults with a suspected cognitive impairment that need for assistance. This assessment is portable, ecological validity and quick to administer. Kettle test is recommended to assess executive functions for stroke in term of clinical utility because it has the shortest administration time which is less than 20 minutes and requires less equipment (Poulin, Korner-Bitensky, & Dawson, 2013).
1.3 Problem Statement

Effective communication with patients and health care workers is important to maintain safe and quality health that is provided. According to Almutairi (2015), an effective communication between the relationships of patient and clinician can improve the satisfaction of patient, follow to the medical recommendation and the improved healthcare outcomes. Barriers in communication between the patient and healthcare worker can cause many consequences to the patient. Excess pain, unneeded errors, poor quality services and also death is the consequences of communication’s barrier between patients and the healthcare worker (Almutairi, 2015).
Understanding the population’s culture is an important aspect when conducting an evaluation. Ignoring the population’s culture may cause biased in the result obtained, so, it is important to reduce or eliminate the culturally biased. It cannot be taken for granted to compare the result obtained in one culture to all other cultural groups because the score differences observed in that comparisons may have a partly or entirely different meaning (van de Vijver ; Tanzer, 2004). The language, content or item used in an assessment can be culturally biased because not all population is adapted to it. Thus, cross-cultural adaptation is addressed to establish the equivalency and quality of the new version of assessments.
Elderly people also tend to easily exhaust when doing the activities that take a longer time due to health factor and medication. Lack of energy is common among the elderly and known as a “geriatric syndrome”. Excessive tired may cause harm and reduce the productivity and their ability to complete the task. Milanovic et al. (2013) point out that it is theoretically that physical capacity is necessary to do everyday tasks independently and without early onset of fatigue which is represent the people’s physical capacity but the elderly faced the difficulties in everyday activities and normal functioning as a result of declining the physical fitness such as strength, agility, stamina, and flexibility due to aging process. Consequently, test or activities that take longer times to complete may result in a decrease of performance in elderly people and they will avoid the test.

The standardized assessment that evaluates executive function are Lowenstein Occupational Therapy Cognitive Assessment -Geriatric (LOTCA-G), Dynamic-Lowenstein Occupational Therapy Cognitive Assessment-Geriatric (D-LOTCA-G), Kettle Test (KT) and Executive Function Performance Test (EFPT) but there is only a few of assessment that is performance-based assessment such as Kettle Test and EPFT. However, EPFT is very lengthy to conduct on elderly people and there is no other current type of performance-based assessment that is suitable for the elderly population in Malaysia. So, the KT is another performance-based assessment that takes a shorter time to screen a variety of cognitive areas. Unfortunately, there is no Bahasa Malaysia version of KT. It may cause the result is biased toward elderly people who do not comprehend the instruction given as English is not Malaysian’s mother language to the non-bilingual individual. Besides that, the item and ingredient used in that assessment also may not suitable for our culture. These barriers may cause the individual to score lower even though they are not cognitively impaired due to health care workers may underestimate the abilities of them. Thus, the aim of the study is to translate and validate the Kettle Test to Bahasa Malaysia version (M-KT). Hence, this study will improve accessibility and provide more method to evaluate the executive function that is in Bahasa Malaysia and adapt with Malaysian culture.
1.4 Significance of Study

The translated version of Malay-Kettle Test (M-KT) is useful to briefly evaluate the cognitive skills which are an executive function in functional context among elderly. This study may provide advantages to Malaysian Health Professional to assess the executive function among older people in institutions as well as in community living in Malaysia. In addition, this study also to provide an assessment that is culturally appropriate and reduce the language barrier in the Malaysian population. So, this assessment will be easier to be administered as most of them are able to communicate and comprehend in Bahasa Malaysia. The reason of this study also because there are only a few assessments that evaluate the performance-based of executive function in older people such as Kettle Test and Executive Performance Functional Test (EPFT). However, EPFT takes a longer time to assess in older people. Thus, this study will provide more method to evaluate executive function in Bahasa Malaysia and culturally adapted to this population.
1.5 Research Objectives and Research Questions

1. Phase 2a: Translation Phase
• Research objective: To translate the instruction of original version of KT into BM language and back translate it.
• Research question: Can the instruction of the original of KT be translated into BM language and be back translate it?

2. Phase 2b: Cultural Validation of Item
• Research objective:
o 2b (1): To determine the comprehension regarding the name of the items and the use of the item.
o 2b (2): To determine the substitute items unknown by the participant in stage 2b (1)
• Research Questions:
o 2b (1): Do the participants able to understand and comprehend the name and the use of item?
o 2b (2): Does the items in stage 2b (1) needed to be substituted?

3. Phase 3: Pre-Test The Experimental Version
• Research objective:
o To identify problems in the translated text.
o To identify the modification needs in the adapted version.
• Research Questions:
o What is the problem in the translated text?
o What is the modification needs in the adapted version?

4. Phase 5: Evaluation of The Reliability (Internal Consistency)
• Research objective: To check the internal consistency and time stability of the M-KT
• Research questions: Does the M-KT have internal consistency and time stability compared to the preliminaries version?

1.6 Hypothesis

Null hypothesis (H?):
1. There is no significant difference in results of test and retest of the M-KT after 2 weeks.

Alternative hypothesis (HA)
1. There is a significant difference in results of test and retest of the M-KT after 2 weeks.


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