Evaluating Strategy Use,Online Awareness and Memory Performance Using the Contextual Memory Test Version 2 (CMT-2) in Healthy Adults

Abstract

Objective

The Contextual Memory Test-2 (CMT-2) is an updated version of the CMT, which is a standardized occupational therapy assessment to evaluate an individual’s memory, awareness and strategy use to guide occupational therapy interventions. This study aimed to examine, amongst younger adults (<40 years old) and middle-to-older adults (>40 years old) in Singapore, (1) the relationship between strategy use and memory performance (2) the relationship between online awareness and memory performance, and (3) explore the relationship of memory performance and online awareness with age. The secondary objective was establishing preliminary normative data on CMT-2 for the Singapore adult population.

Methods

One hundred and thirty-two healthy participants aged 18–71 were recruited via convenience sampling and underwent virtual or face-to-face assessment. CMT-2 was administered to assess their immediate recall (IR), delayed recall (DR), total recall (TR), strategy use, and online awareness of performance through prediction and estimation discrepancies.

Results

Higher recall scores were found for efficient strategies as compared to inefficient (IR: p = .012; DR: p = .003; TR: p = .003). For different strategy types, ‘context’ yielded higher recall scores than ‘limited association’ (IR: p < .001, DR: p = .016). During IR, ‘association’ also obtained a higher recall score than ‘limited association’ (p = .007). Significant strong negative correlation of IR prediction discrepancy with recall score was found (r_s (130) = -.611, p < .001).

Conclusion

The preliminary normative data of CMT-2 among healthy adults in Singapore highlighted the role of effective memory strategies and online awareness in memory recall performance, suggesting the prioritization of these areas during interventions.

Keywords

contextual memory test memory performance strategy use online awareness cognitive assessment

Introduction

The Contextual Memory Test (CMT) (Toglia, 1993) was developed as a paper-based occupational therapy assessment tool to evaluate self-awareness of memory performance, strategy use and recall of 20 everyday objects related to a scene or context (e.g., morning scene, restaurant scene) in individuals with memory difficulties. Standard questions are asked before and immediately after a recall task to examine prediction, estimation and self-perceptions or awareness of memory performance. Memory strategies used are also probed through questions asked immediately after the recall task. The CMT differs from standardized memory tests that require recall of word lists or abstract shapes. The inclusion of everyday objects from daily life scenes in the CMT, combined with a focus on self-awareness and strategy use, provides unique information regarding memory functioning that can be used to guide occupational therapy intervention. The CMT can also be used to screen for individuals with memory impairments, and evaluate changes after treatments (Liao et al., 2020).

Psychometric properties including validity and reliability of the CMT have been established in various studies. The CMT discriminates between adults with and without various conditions, such as mild cognitive impairment (Liao et al., 2020), Alzheimer’s disease (Gil & Josman, 2001), acquired brain injury (Toglia, 1993), multiple sclerosis (Goverover et al., 2018) and chronic schizophrenia (So et al., 1997) as well as between healthy adults across different age groups (Josman & Hartman-Maeir, 2000). Published norms are available from ages 18 to 86 (Toglia, 1993) and cross-cultural studies have also been conducted (Josman & Hartman-Maeir, 2000). The CMT has been used in studies to assess the effects of occupational therapy interventions (such as cognitive rehabilitation and lifestyle redesign) on functional cognition (Chang et al., 2023; Goverover et al., 2018), and to evaluate effectiveness of use of context as a strategy for different population groups (Liu et al., 2024).

However, as the CMT was published in 1993, some items used in the assessment were perceived as outdated and less relevant in today’s setting (e.g., ashtray). Moreover, it is limited to paper-based assessment, and utilizes black and white line drawings which have less resemblance to everyday life. Hence, the CMT-2 was developed as an updated version of the CMT. Changes include the ability to perform the test online so that it can be used virtually, updated and replaced items, colored photos instead of black and white drawings, and revised strategy use scoring. In addition to the morning and restaurant versions for adults, other changes include a new morning and school scene for children (age 8 and above) is also freely available online. Currently, there are no published norms for the CMT-2. As occupational therapists commonly incorporate strategy-use and may focus on improving awareness of memory performance to enhance occupational performance (Giles et al., 2022; Goverover et al., 2024), a comprehensive assessment of a client’s strategy use and awareness using the CMT-2 would provide valuable information for occupational therapy treatment.

Since efficient and effective strategies are generally associated with better occupational performance, it is important to understand the underlying strategies used in memory tasks by healthy people and their relation to memory performance. Strategies can involve associating meaning to the material or adding contextual information to the item. The use of efficient strategies is intertwined with self-awareness, as self-awareness facilitates a person’s adoption of strategies to support functional performance. One key component of awareness is online awareness. It involves awareness within the context of a task such as appraisal of task difficulty and self-assessing or estimating actual performance (Toglia & Foster, 2021; Toglia & Kirk, 2000). The discrepancy between estimated performance (done before or after a task) as compared to actual memory performance can be used as an indication of awareness. Studies have found that less self-aware individuals perform poorer in cognitive tasks. Marks et al. (2024) found that those who were categorized as aware performed better on several other functional cognition performance tests compared to those categorized as unaware. Arora et al. (2021) also found that lower-performing adults overestimated their performance on a functional cognitive task and used fewer strategies. Hence, online awareness appears to be critical to functional performance, related to strategy use, and is an important component of assessment.

Age-related cognitive decline begins in early to middle adulthood, with different domains of memory declining at different rates (Hartshorne & Germine, 2015; Salthouse, 2019). Working memory and short-term memory have long plateaus of high performance from the late teens into the thirties, while semantic memory peaks in late 40s (Hartshorne & Germine, 2015). However, limited studies examine memory and online awareness across the adult lifespan, as research commonly focuses on comparing young and older adults. Such studies are also more experimental, involve novel tasks to pick up subtle differences and not contextualized to daily items.

This study attempted to delve deeper into memory and self-awareness across younger (<40 years old) and middle-to-older aged adults (>40 years old) in Singapore and to understand more about the relationship between efficiency of memory strategies, online awareness, and memory performance. Therefore, the main objectives of this study were to examine, amongst younger adults and middle-to-older adults in Singapore, (1) the relationship between strategy use (types and efficiency) with memory performance; (2) the relationship between online awareness and memory performance; and (3) explore the relationship of memory performance and online awareness with age. The secondary objective was to establish preliminary normative data for the Singapore adult population on the CMT-2.

Methods

Participants

This was a cross-sectional validation study on the Singapore healthy population using CMT-2. Healthy participants were recruited through convenience sampling, using snowballing techniques and e-flyers. The inclusion criteria were (1) age 18 years and above, (2) English speaking, (3) community-dwelling adults who were independent in daily activities, (4) good vision with or without corrective lenses, and (5) able to give independent consent. Participants who declared a history of neurological disorder (e.g., brain tumor, stroke), or a condition that could impact results (e.g., hospitalized for a psychiatric illness) were also excluded from this study.

Participants aged above 65 were screened using the Montreal Cognitive Assessment (MoCA)-Singapore (Dong et al., 2010; Nasreddine et al., 2005) for cognitive impairment. While Petersen (2004) recommended that performance of 1.5 standard deviations (SD) below the mean on memory tests (matched for age and education) indicated some presence of mild cognitive impairment, a local study found that a cutoff score of 27 on the MoCA could be used to estimate participants as healthy, with an additional correction point for participants with ≤10 years of education (Ng et al., 2013). Participants who scored <27 were excluded from data analysis.

Instrument – CMT-2

The CMT-2 involves immediate and delayed recall of 20 colored photos of objects related to a scene. This research study administered the Morning – adult scene, as the pictures were more culturally relevant to Singapore. The following describes the 3 main components measured during the CMT-2 assessment.

Recall

Participants viewed the morning scene for 90 seconds. Immediate recall (IR) and delayed recall (DR) (after 15 minutes) were both assessed. IR and DR scores ranged from 0–20 and were added together for the total recall (TR) score (0-40).

Awareness

Online awareness of performance was measured by the difference between recall scores and (1) number of items the participant predicted they would remember before the test (prediction discrepancy), and (2) estimated number of items recalled after the test (estimation discrepancy). The number of items predicted or estimated was subtracted from the actual recall score. A score of 0 indicated accurate prediction or estimation. Positive numbers indicated overestimation of abilities and negative numbers indicated underestimation of abilities.

Strategy Use

Strategy use was rated according to the CMT test guidelines and scoring criteria based on responses to an after-task interview. Strategies were rated on a hierarchy according to their effectiveness in chunking or associating information, with a strategy rating from 0–4. For example, strategies that included use of the context (morning, getting ready to leave the house), meaningful associations (mentions groups with ≥3 items), or elaboration (linking items in a story) were assigned higher ratings, compared to those who only identified partial context, used limited associations (using pairs or one small group), studied location or order of pictures, or pictured the item without meaningful associations or groupings.

If participants did not report the use of context, they were asked if they thought of a place or scene to recall. Use of context was classified and rated from 0–3 (3 = Morning context, 2 = Related context, 1 = Partial context, 0 = None). In the case of the morning context, articulating the context of a person getting ready in the morning to leave house will meet the full ‘morning context’, citing ‘bathroom’ etc. will be scored as ‘related context’, while identifying a group of more than 2 items within the scenario will be scored as ‘partial context’.

Strategy score for each recall was obtained from the summation of their respective strategy and context ratings, ranging from 0–7. Strategies were then categorised by their efficiency according to their strategy scores (6-7 = efficient, 3- 5 = inefficient, 1-2 = minimal, 0 = absent). Total strategy score (TSS) for TR (0-14) was then formed by the summation of IR and DR strategy scores. The detailed definition of the strategies and context ratings can be found on the CMT-2 website (MultiContext, 2019).

Procedure

A test administrator account on the CMT-2 website was obtained to administer the web-based assessment. Administration was done in a single study visit, taking 35–50 minutes, either face-to-face or virtually. As the MoCA necessitates a face-to-face visit, sessions for participants above 65 years of age were conducted face-to-face. The assessment was done in a quiet and consistent environment, arranged at the participant’s convenience.

Upon completion of the assessment, test results were automatically generated by the online CMT-2 system. Scores were generated under 3 domains: (1) Recall Performance (2) Awareness, and (3) Strategy Use.

Data Analysis

IBM SPSS (Version 28.0) was used for data analysis (IBM Corp, 2021). The Shapiro-Wilk normality test for normal distribution found that the majority of data across the groups was not normally distributed, with the exception of DR and TR scores under categories of strategy types and efficiencies. Friedman analysis was used for analysis of discrepancies across timepoints, while Spearman correlation test was used for analysis of correlations. Chi-square test of independence was used to analyse for differences between strategies used amongst age groups.

For pair and groupwise comparison of strategy types and efficiencies that involve N ≥20, data was normally distributed for strategy types used during DR, and strategy efficiencies during TR. Hence, for pairwise comparisons, the independent t-test was used for data with normal distribution (inefficient and efficient strategies for TR), while Mann-Whitney U-Test was used for pair analysis of the remaining skewed variables. For group analysis, One-way ANOVA was used for normally distributed data (‘Limited association’, ‘Association’ and ‘Context’ during DR), while the Kruskal-Wallis H-Test was used for data without normal distribution. Subsequent pairwise post-hoc comparison used Bonferroni adjustment to identify the pairs with significant differences. The p-value of 0.05 was used to identify significant differences during analysis.

Ethical Considerations

Ethics approval was obtained from the Singapore Institute of Technology Institutional Review Board before commencement of the study (Approval Number: 2022211).

Results

Demographics

A total of 132 participants met the eligibility criteria. They were aged between 18–71 (M = 41.6, SD = 16.38), with the majority being female (63.6%), Chinese (90.2%) with an average of 15 years of education. Although the original intent was to examine 3 age groups, (1) 18 to 39; (2) 40 to 64; and (3) 65 and above, the sample size for participants aged 65 and above was small (N = 10). These older participants did not exhibit significant differences in memory performance and online awareness compared to participants aged 40 to 64. Hence, data for older adults were combined with those for middle-aged adults, forming age group 2. The younger age group (18-39) is consistent with the original CMT and is based on literature indicating that changes in memory performance can be detectable from age 40 onwards (Andersen, 1976; Foster et al., 2007). Table 1 shows the participants’ demographic information. There were no significant associations between demographic variables including gender, age and education level and the CMT-2 scores.

Table 1.

Demographic Data of Participants

	All	Age group 1 (18–39 years old)	Age group 2 (≥40 years old)
Participants, N (%)	132 (100)	67 (50.8)	65 (49.2)
Age, mean years (SD)	41.6 (16.38)	27.0 (5.38)	56.7 (8.00)
Age range	18–71	18–39	41–71
% female	63.6	61.2	66.2
Education, mean years (SD)	15.26 (2.79)	16.1 (1.88)	14.4 (3.27)
% Ethnicity
Chinese	90.2	91.0	89.2
Filipino	1.5	1.5	1.5
Indian	1.5	0	3.1
Malay	6.8	7.5	6.2

CMT-2 Scores

CMT-2 scores of the participants are presented in Table 2. Results showed a slight declining trend in recall and strategy scores from age group 1 to group 2, however it was non-significant. The proportion of strategy use was also not significant between the two groups.

Table 2.

Recall Score, Strategy Use and Awareness Based on Age Group

	All	Age group 1 (18–39 years old)	Age group 2 (≥40 years old)	p
Recall score
IR
Mean (SD)	14.43 (2.64)	14.64 (2.90)	14.28 (2.4)
Median (IQR)	15.00 (13–16)	15.00 (1–17)	14.00 (13–16)	.379
DR
Mean (SD)	13.55 (3.01)	13.77 (3.00)	13.31 (3.11)
Median (IQR)	14.00 (12–16)	14.00 (12–16)	13.00 (12–16)	.549
TR
Mean (SD)	27.98 (5.34)	28.41 (5.65)	27.59 (5.17)
Median (IQR)	28.00 (25–32)	29.00 (25–32)	27.00 (24–32)	.432
Strategy score
IR
Mean (SD)	5.23 (1.98)	5.39 (1.85)	5.02 (2.17)
Median (IQR)	6.00 (4–7)	6.00 (4–7)	6.00 (3–7)	.697
DR
Mean (SD)	4.95 (2.28)	5.20 (2.10)	4.62 (2.42)
Median (IQR)	5.00 (3–7)	5.00 (4–7)	5.00 (3–7)	.498
TR
Mean (SD)	10.18 (4.04)	10.59 (3.81)	9.64 (4.29)
Median (IQR)	10.00 (8–14)	10.00 (8–14)	10.00 (7.5–14)	.452
Awareness
IR Prediction Discrepancy
Mean (SD)	−4.10 (3.52)	−4.05 (4.00)	−4.15 (3.14)
Median (IQR)	−4.50 (−6-(-2))	−4.00 (−7-(-2))	−5.00 (−6-(-2.5)	.965
IR Estimation Discrepancy
Mean (SD)	−1.95 (2.38)	−2.20 (2.81)	−1.80 (1.82)
Median (IQR)	−2.00 (−3.5-(-2))	−2.00 (−4-0)	−2.00 (−3-0)	.384
DR Estimation Discrepancy
Mean (SD)	−1.13 (2.08)	−1.43 (2.43)	−0.89 (1.64)
Median (IQR)	−1.00 (−2-0)	−1.00 (−3-0)	−1.00 (−2-0)	.133

Note. IR = Immediate Recall; DR = Delayed Recall; TR = Total Recall.

Prediction of memory abilities before IR indicated that participants thought they would only be able to remember half the number of items (M = 10.33, SD = 2.66). Online awareness of performance measures indicated that the majority of participants underestimated their actual recall score. There were significant differences in prediction/estimation at different time points (p < .001). Participants had greater underestimation of performance before IR as compared to after DR (p < .001).

Online Awareness

Proportion of Participants in Overestimation and Underestimation in Prediction/Estimation of Recall Performance

The majority of participants underpredicted and underestimated their recall scores in both IR and DR (see Table 1 in Supplementary Material). With increased task knowledge and experience from pre-task (IR prediction) to post-task (DR estimation), the percentage of participants who estimated accurately also increased (from 6.8% in IR prediction to 30.3% in DR estimation). Very few participants overestimated their performance by more than 1 (IR prediction: N = 8; IR estimation: N = 5; DR estimation: N = 7).

Prediction/Estimation Discrepancy and Memory Performance

Prediction and estimation discrepancies showed significant negative correlations with the number of recalled items in their respective recalls (see Figure 1 in Supplementary Material). IR prediction discrepancy showed a significant negative strong correlation with the number of recalled items (r_s (130) = -.611, p < .001). Estimation discrepancies for IR and DR showed significant negative weak correlations with the number of recalled items (IR: r_s (130) = -.175, p = .045; DR: r_s (130) = −.207, p = .017). These associations suggested that increased underprediction and underestimation of recall ability may be related to better recall performance.

Use of Context in Strategy Use

Almost half of the participants reported using the morning context, either when describing their strategy type or on further probing by the researcher, as a strategy for their IR (N = 63, 47.7%) or DR task (N = 61, 46.2%). For partial context (limited associations), more participants used the strategy during IR (N = 23, 17.4%) compared to DR (N = 16, 12.1%), whereas a similar number of participants used related context (bedroom or bathroom rather than morning context) in both recalls (IR: N = 35, 26.5%; DR: N = 36, 27.3%). Lastly, fewer participants reported no use of context in IR (N = 11, 8.3%) than DR (N = 19, 14.4%).

Strategy Use and Online Awareness of Performance

Only a small number of participants (N ≤ 10) reported strategies such as general association, repetition, studying location, or visualizing a picture without meaningful associations during recall. These strategies are considered to be inefficient and are assigned lower ratings. Similarly, very few participants reported no strategy use following IR (N = 3) or DR (N = 11). A greater number of participants (N ≥ 20) reported strategies that are considered more efficient, such as ‘Context’, ‘Association’, and ‘Limited association’. One exception was the use of elaboration. This strategy is considered efficient, but was used by very few participants (N < 10). In general, participants who used less efficient strategies also appeared to have lower recall scores, with the exception of “No strategy” (N = 3), and “Studying location” (N = 6). The number, percentage of participants that reported different types of specific strategies and their respective median recall scores are detailed in Supplementary Material, Table 2.

Figure 1 presents the distribution of recall scores and IR prediction discrepancies among the different strategy types and efficiencies. Strategies used by less than 20 participants were excluded from analysis due to small sample size.

Figure 1

Box Plot of Recall Scores across (a) Strategy Types and (b) Strategy Efficiencies, with Significant p-values Indicated as *: p < 0.05, **: p < 0.01, ***: p ≤ 0.001

Recall Scores Among Different Strategy Types and Efficiencies

Significant differences were found in IR and DR scores among different types of strategies (IR: p=<.001; DR: p = .017) (see Supplementary Material, Table 3). Pairwise comparison showed that IR score for participants who used ‘Limited association’ was significantly lower as compared to more effective strategies such as context (Z = −3.51, p = .001) and ‘Association’ (Z = −3.05, p = .007). DR scores for participants who used “Limited association” were significantly lower than those who used ‘Context’ to help them remember (t = −3.01, p = .015).

Recall scores also increased with greater efficiency of strategy across IR, DR (see Supplementary Material, Table 4). Pairwise comparison showed significant differences in IR and TR recall scores between inefficient strategies and efficient use of strategies (IR: Z = −2.52, p = .012; DR: Z = −3.01, p = .003; TR: t = −3.08, p = .003). Higher IR, DR and TR scores were attributed to efficient strategies.

Prediction Discrepancy Among Different Strategy Efficiencies

There is a general trend of participants who used more efficient strategies underpredicting their performance more (‘minimal’: M = −1.11, SD = 4.81, ‘inefficient’: M = −3.75, SD = 3.12, ‘efficient’: M = −4.68, SD = 3.44). Moreover, those who used minimal strategies demonstrated a wide range in their ability to predict actual performance as compared to efficient strategies. However, analysis involving strategy efficiencies with N ≥ 20 showed no significant differences in prediction discrepancies between inefficient and efficient strategies.

Discussion

This study explored the relationship between strategy use, awareness and memory performance of young and middle-to-older aged adults in a healthy Singapore population. More effective memory strategies, particularly those involving contextual encoding and meaningful associations, appeared to be associated with better recall performance. Additionally, greater underestimation of memory ability correlated with higher recall scores and more efficient strategy use. No significant differences in memory performance between younger and middle-to-older aged adults were found, possibly due to semantic familiarity of the task.

The CMT-2 scores from this study done in Singapore showed slight differences with the original CMT norms from the United States (US). The younger and middle-to-older aged adult sample in this study obtained lower recall scores by a magnitude of approximately 1, as compared to the US normative data in the original CMT. These results were similar to the cross-cultural study by Josman and Hartman-Maeir (2000), where Israeli younger adult participants obtained lower DR and TR scores than US norms. While Josman and Hartman-Maeir (2000) hypothesized the differences in the study to be due to education level, in this study, differences could be attributed to cohort differences, especially given that the normative data for CMT was collected more than a decade ago. Moreover, cultural differences could also be present. The pictures in CMT-2 may have reduced relevance to participants’ daily life, which may have influenced their ability to encode the items. For example, while the CMT-2 includes pictures of physical newspaper and wallet, with the digital transformation of lifestyle in Singapore, there has been a shift away from physical newspaper readership (Nie et al., 2013) and usage of physical cash and wallet (Tan, 2022). Another example would be that instead of bar soap, liquid soap is more commonly used in current households. This would be congruent with findings by Sun et al. (2018), where memory performance improved when items were culturally adapted for the Taiwanese population. However, as the scope of this study did not include analyzing the items in the CMT2 for cultural relevance to Singapore, more analysis is recommended to be done in the future to draw any conclusion.

It is interesting to note that the overwhelming majority of healthy participants underestimated memory abilities. This finding was consistent with the normative data of CMT (Toglia, 1993) in both the US and Israel (Josman & Hartman-Maeir, 2000) and with results of Chudoba and Schmitter-Edgecombe (2020) who examined prediction and estimation of verbal immediate and delayed recall. In contrast, previous studies on the CMT have found that the majority of those with acquired brain injury and Alzheimer’s Disease significantly overestimated performance and had lower recall scores (Gil & Josman, 2001; Toglia, 1993). These findings are consistent with a phenomenon known as the Dunning–Kruger effect. The Dunning–Kruger effect indicates that a person with low ability in a task overestimates their competence, while those with high ability tend to underestimate performance (Kruger &, Dunning, 1999). Studies across domains and populations have supported this effect in the literature (Schlösser et al., 2013; Schoo et al., 2013). The initial CMT studies found that overestimation was associated with worse recall scores, and underestimation was associated with better recall scores, regardless of group (healthy or clinical). However, the percentage of overestimators was significantly higher in clinical groups (Toglia, 1993). In the current study, there were very few healthy participants who overestimated performance. Overestimation has also been associated with worse performance on a functional cognitive task involving executive functions in persons with stroke (Jaywant et al., 2022), acquired brain injury (Salazar-Frías et al., 2025), as well as in lower performing healthy adults (Arora et al., 2021)

Adult participants in this study also showed greater underestimation than the participants of the original CMT (Toglia, 1993) (IR prediction discrepancy: SG = −4.10, US = −2.12; IR estimation discrepancy: SG = −1.95, US = −0.85; DR estimation discrepancy: SG = −1.13, US = −0.72). It is also noted that the differences in discrepancy were reduced with task experience in all studies. This suggests that information learned from task experience in healthy adults (accurate self-monitoring) can update one’s online awareness and change self-perception of abilities as hypothesized by the dynamic comprehensive model of awareness (Toglia & Kirk, 2000).

The majority of healthy people in this study used higher-rated strategies, particularly context and associations. One exception to this was the independent use of elaboration. This strategy is considered efficient, but it was not reported to be used as frequently. This could be because elaboration or linking together things in a story frequently overlapped with context, as many people reported a story within the context of the morning scene. The CMT-2 scoring criteria only allow one strategy rating to be assigned (highest strategy used). Although both elaboration and context are assigned the same high strategy rating, the context strategy was selected if the morning scene was mentioned. Therefore, the actual use of elaboration strategies was masked and may be inseparable from the use of the contextual theme. The high frequency of contextual and meaningful association strategies is in line with previous CMT research findings (Gil & Josman, 2001; Toglia, 1993).

Very few healthy participants (N < 10) reported use of inefficient strategies such as studying location, repetition, or visualization without meaningful association, and only three participants reported no use of strategies during IR. In general, descriptive observations support the objective findings and illustrate that those who used less efficient strategies appeared to show a general trend toward lower recall, particularly for delayed recall. However, there were a couple of exceptions for IR, such as “Studying location and “No strategy”. One possible reason is that efficient strategy use may be more important for retention over time, or delayed recall, rather than immediate recall. This is consistent with the Levels of Processing Memory Theory, which suggests that the deeper information is processed (meaningful or contextual associations), the more durable the memory (Craik & Lockhart, 1972).

Although the study was unable to fully examine the impact of strategy types on recall that were not commonly used by participants, comparison of recall scores amongst use of limited association (less efficient) to the use of association and context (more efficient) could be done.

Higher-rated strategies (e.g., use of context or meaningful associations) had significantly higher recall scores than limited association, also suggesting that deeper encoding could enhance the durability of memory. Specifically, usage of morning ‘Context’ showed the most pronounced differences in effectiveness, followed by ‘Association’, indicating that they were particularly effective for the task at hand. This aligns with existing research, suggesting that task-specific selection of memory strategies plays a crucial role in mediating recall performance (Dirette, 2015; Dunlosky & Hertzog, 1998), In this study, the use of context, specific to “getting ready in the morning”, creates a schema that helps people organize new information they encounter, thereby reducing cognitive demands for encoding and recalling information (Craik & Bosman, 1992). Taken together, findings are congruent with existing literature on the relationship between depth of encoding, context, and memory performance.

Increased underprediction and underestimation were associated with better recall performance. While it was observed that participants who underpredicted their performance also used more efficient strategies and had better immediate recall in this study, there were no significant differences found. However, association between strategy use and awareness was previously found with the CMT (Toglia, 1993) as well as in recent studies examining the association between awareness, strategy use, and performance (Arora et al., 2021; Salazar-Frías et al., 2025). More research is needed to understand the interplay between strategy use and subsequent prediction of memory performance.

Findings from this study did not support the hypothesis that there would be differences in memory between younger and middle-to-older aged participants. This appeared to be inconsistent with existing studies on age-related episodic and working memory decline (Salthouse, 2019). One reason could be that the CMT-2 requires recall of morning routine items that are highly relevant to the participants’ semantic knowledge and therefore, more resistant to age effects (Hartshorne & Germine, 2015; Loaiza, 2024). In addition, the high proportion of participants using the morning and related context without external cues suggested that the semantic relationship between items was apparent. Hence, performance would less likely be subjected to age-related decline as compared to novel or abstract tasks used in the majority of existing studies. Furthermore, the original CMT also did not show significant differences in memory scores between young and middle age groups (Toglia, 1993).

Implications for Occupational Therapy Practice

The results of this study highlighted the importance of self-appraisal before and after memory tasks and use of effective memory strategies. Therefore, occupational therapists should consider strategy use and online awareness alongside memory performance during assessments and interventions.

Memory appears to be enhanced when items are highly relevant to daily life and have contextual features that provide cues for association and elaboration. Therefore, establishing connections to familiar knowledge and experiences during occupational therapy interventions can assist service users in managing memory performance problems (Mraz et al., 2023; Tulliani et al., 2023). Occupational therapists can also promote the use of context as a strategy in supporting memory performance (Liu et al., 2024). Furthermore, context promotes the usage of efficient strategies such as elaboration and association, which also deepens the encoding process and enhances memory performance (Mraz et al., 2023). Given that online awareness is closely associated with performance (Arora et al., 2021; Marks et al., 2024), occupational therapists may also focus on efforts aimed at enhancing self-monitoring and appraisal of task performance. Incorporating self-evaluation before and after a strategy-based occupational therapy intervention appears to facilitate self-awareness and can improve functional performance (Goverover et al., 2024).

Limitations

A key limitation in this study was the small sample size of the older adult population, which led to the collapsing of this age group with middle-aged adults. Hence, middle-to-older aged adults had larger age variability (SD = 8.00) as compared to younger adults (SD = 5.38), which may have masked age-related differences in the middle-to-older aged group. Moreover, as only participants up to 71 years old were included, the sampled data in this study does not represent the performance of older adults across the spectrum of young-old, old-old and the oldest-old. A larger sample size across all age groups, but particularly older adults, is needed to further examine differences in performance across ages. Moreover, since the administration of the CMT-2 was only available in English, only English-speaking older adults were recruited, despite a significant portion of the older adult population not being fluent in English (Institute of Policy Studies, 2020). Further research on the older-adult population using a different language medium will be needed.

Additionally, results regarding the association between specific strategies, no strategies, and recall were limited by low sample size. While the frequency of inefficient strategies is expected to be low in a healthy sample, the limited frequencies in these types of strategies precluded the ability to examine the effect of all specific strategy types on recall. Future research across both healthy and clinical populations is needed to more fully assess the influence of inefficient strategies on recall and to confirm the trends observed in this study. Results also suggest that further refinement of the CMT-2 strategy rating guidelines is needed, particularly to capture combinations of strategies used.

As this study did not examine the restaurant scene of the CMT-2, the parallel form reliability of the CMT-2 was not investigated. The use of the restaurant scene, as compared to the morning scene, could also have further implications on cultural differences. With respect to the morning scene used in this study, as the sessions were carried out in participants’ home or office environments, external cues from their surroundings might also have prompted them to use context as a strategy.

Lastly, while the findings of this study could be used to inform clinical practice, further research on the clinical population would be needed to understand awareness and the use of strategies among different diagnostic groups.

Conclusion

The preliminary data of CMT-2 among young and middle-to-older aged healthy adults in Singapore highlighted the role of effective memory strategies and online awareness in memory recall performance. To enhance occupational performance in memory tasks, facilitating the acquisition of efficient strategy use and greater online awareness could be prioritized during cognitive rehabilitation. For future research, local translations of the CMT-2 could be explored to study the Singapore older adult population. Future research could also be conducted to collect data on the clinical population, so as to validate this occupational therapy assessment tool for informing clinical practice.

Supplemental Material

Supplemental Material - Evaluating Strategy Use, Online Awareness and Memory Performance Using the Contextual Memory Test Version 2 (CMT-2)

Supplemental Material for Evaluating Strategy Use, Online Awareness and Memory Performance Using the Contextual Memory Test Version 2 (CMT-2) by Kai Ling Koh, Bhing Leet Tan, Rachel Rui En Pek, Khiella Mae Felipe Wong, Xin Lin Wong and Joan Toglia in Hong Kong Journal of Occupational Therapy

Footnotes

Acknowledgements

The authors would like to express their gratitude to the participants in the study for their time and effort.

ORCID iDs

Kai Ling Koh

Bhing Leet Tan

Joan Toglia

Ethical Considerations

Ethics approval was obtained from the Singapore Institute of Technology Institutional Review Board before commencement of the study (Approval Number: 2022211).

Consent to Participate

Written informed consent was obtained from participants through signing the participant consent form before administering the CMT-2.

Funding Statement

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Singapore Institute of Technology Health and Social Sciences programme as part of the Bachelor of Science in Occupational Therapy honours thesis.

Declaration of Conflicting Interest

Joan Toglia is the author of the CMT and CMT-2. The remaining author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data is hosted by the Singapore Institute of Technology (SIT). Data may be released on request from the corresponding author.*

Supplemental Material

Supplemental material for this article is available online

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