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Andrea Betts, OTR/L Julianne Cooper, OTR/L

Clinical Implementation of the Allen Cognitive Levels Scale (ACLs)

Administering and Applying the Levels to Guide Interventions and Discharge Planning

Course Objectives:

▪ Discuss the 6 levels of cognition and their implication on functional performance

▪ Explain how an ACL score can guide intervention and discharge planning among the IDT

▪ Demonstrate administration of ACL leather lacing and placemat to assess cognition

Background information

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The Allen Cognitive Levels Scale (ACLs)

▪ Developed by Claudia Allen OTR, and colleagues in the late 1960’s in in-patient mental health setting

▪ Based on observable “predictable patterns of performance” with daily activities

▪ Goal to help evaluate ability to:▪ Make decisions▪ Function independently▪ Safely perform basic skill▪ Learn new tasks.

ACLS▪ OTs use to understand optimal functional performance in the

presence of potential cognitive impairment

▪ Focus to understand “Functional Cognition”

▪ Is appropriate for both temporary and permanent impairments

▪ Assesses the “Working Memory,” using an unfamiliar task in order to stage the disease process

Purpose of the ACLS▪ Quick measure to obtain:

▪ Global cognitive processing capabilities▪ Learning Potential▪ Performance Abilities▪ Detect suspected or unrecognized issues with functional

cognition

▪ Use of Evidence Based Practice for patient approach, activity analysis, and set realistic goals

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Purpose of the ACLs▪ Goal of interventions is to promote safe engagement in

activities, allowing the clients to experience their Best Ability to Function in supportive environments

▪ Guide Discharge Planning

▪ Anticipate d/c location▪ Determine level of supervision▪ Create restorative programs and/or functional maintenance

programs▪ Guide Activity programs

Psychometrics▪ Inter-rater reliability: r= .91-99

▪ Test-restest: less reliable due to “point in time”, cognition can fluctuate over time▪ r=.95 in study of 49 subjects with Alzheimers

▪ Validity: r= .55, p=<0.01 between LACLS and Medication Adherence Rating Scale

▪ Validity: r= .90 and p=<0.0001 for ACLS and Mini Mental Status Exam (Japanese Version)

Psychometric information from the Allen Cognitive Group/ACLS&LACLS Committee “ACLS-5 and LACLS-5 Test: Psychometric Properties and Use of Scores for Evidence-Based Practice”

ACL Levels

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The Levels▪ Consists of 6 levels of increasingly complex abilities with 5

modes of performance under each level for greater specificity

▪ Use of the levels and subset modes can determine a person’s ability, monitor change over time, help plan treatment options, and guide placement for the next care level

Level Title Description

1.0 Automatic actions Able to use protective responses (withdrawal from noxious stimuli)

2.0 Postural actions Able to move body for sitting, standing, walking, and balance; attends to barriers in environment and large objects

3.0 Manual actions Able to handle objects, follow 1-step directions in familiar context, repeat/learn movement patterns, has gross hand use for familiar objects

4.0 Goal directed activity Able to complete a goal, perform ADLs independently, comply with directions, attend to eye-catching visual cues, and familiar actions that accomplish a goal.

5.0 Independent Learning Able to explore new actions and make fine motor adjustments, attends to surface properties, spacial properties, feelings, remembers effects of previous actions to learn new activities

6.0 Planned Activities Able to think about actions before performing them; considers the needs of others; attends to abstract cues, the potential outcome of an action, safety hazards, and social expectations

Level 1: Automatic Actions▪ Cognition is severely impaired

▪ Requires all basic needs to be met by a caregiver with 24-hr care

▪ Responds to sensory interventions

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Level 2: Postural Actions

▪ Cognition is still severely impaired▪ Including loss of language and decrease motor and

visual skills

▪ Can imitate gross motor tasks

▪ They are dependent on caregivers, requiring 24-hour supervision

Level 3: Manual Actions

▪ Cognition and memory are significantly impaired, but they can react to situations and use tools. ▪ Deficits with initiation, sequencing, problem solving, and decision

making

▪ Is easily distracted, cannot learn new behaviors

▪ Needs simple commands, errorless learning, repetitive crafts

▪ Requires 24hr Supervision with cues and assistance for daily care

Levels 4: Goal Directed Activity▪ Cognition is moderately impaired

▪ Can be physically independent with personal care but may need help with initiation and safety

▪ Unsafe to drive

▪ Simple food prep using a sample, follows simple 1-step directions, consistency issues

▪ Repetition for new learning, specific cues

▪ Will need daily assistance or visits

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Level 4 Performance Areas4.0-4.2: 24 hr Supervision▪ Do not overestimate skills, limit introduction of new tasks4.4: Supervised Living - may be left alone part of the day▪ Decreased insight and limited learning; will not remember precautions▪ Will access items in plain sight4.6: Live alone with daily assistance▪ Scans visible environment, out sight does not exist, limited cause/effect4.8: Live alone with daily checks▪ Ability to follow written/diagram instructions but errors still likely▪ Will need assist with anticipation of hazards/problems/changes in routine

Levels 5: Independent Learning

▪ Cognition is mildly impaired

▪ Independent with daily tasks

▪ May have subtle issues with memory and may need assistance with finances and decision making

▪ Able to cook complex 3-course meals, can anticipate errors

Level 5 Performance Areas5.0-5.2: Live alone with weekly checks▪ May be inconsistent with precautions, may follow medication schedule▪ Limited awareness to social/cognitive skills, inflexible▪ Able to learn new techniques with concrete examples▪ May be impulsive with shopping/travel without proper planning5.4: Live alone and works▪ May demo poor judgement, easy to blame others▪ Break tedious tasks into smaller tasks5.6-5.8: Live alone and works▪ May not anticipate unusual situations▪ Better social interactions▪ Understands and remembers safety precautions/instructions

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Level 6: Planned Activities

▪ No cognitive impairment

▪ Independent with daily tasks

▪ Can plan actions.

Communicating ACL levels with the interdisciplinary team

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“At Home With Allen Cognitive Levels” Mary Platt OTR/L

▪ Developed by home health therapist▪ Considers physical, emotional, and social environments▪ Detailed description of each level

▪ Abilities▪ Pattern of behavior: likely to do and not to do▪ Caregiver alert

▪ Fall prevention strategies ▪ Age equivalent

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Documentation

▪ TENS note▪ “Administered LACLS to guide skilled interventions and discharge

recommendations”▪ “Pt scored X, indicating….”

▪ Progress/discharge notes▪ Reflect on why a pt may not be making progress or how POT will

change accordingly▪ “Infer based on ACL of 4.2, pt will need repetitive practice and

caregiver training for hip precautions”▪ Billing

▪ Therapeutic Activities

Supplemental Components to the ACLS

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Cognitive Performance Test (CPT)

▪ Developed by Burns (1990)▪ Not an ADL test, but cognitive-functional information

processing measure▪ Standardized performance-based assessment

▪ Purpose:▪ To explain/predict capacity in various contexts▪ Guide intervention plans▪ Measure/track severity of a condition

▪ Assesses working memory

CPT (cont.)

▪ Looks at patterns of occupational performance with specific tasks

▪ Helps build “functional profile” and find “just right challenge”

▪ Seven subtasks which scores are averaged together▪ Medbox, shop, wash, toast, phone, dress, travel

▪ Specific instructions for task set up and verbal cues

Routine Task Inventory▪ Observation/interview scales for specific ADLs and IADLs

▪ Useful for caregiver observation

▪ Can be time consuming and may not be necessary

▪ Goal is to identify patterns of performance in day to day abilities

▪ Associated with the 6 Allen Levels▪ Has descriptors within each level to check off behaviors

demonstrated to establish a level

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Administering the ACLS

Components of leather lacing

▪ Running stitch: 3.0-3.4

▪ Whipstitch: 3.4-4.4▪ 3 correct stitches, 2 errors to find/fix

▪ Single Cordovan: 4.2-5.8▪ No demonstration to start, can provide standard cues▪ Can give up to 2 demonstrations

Leather Lacing▪ Sit on L side of pt, holding leather in R hand

▪ Environment: good lighting, sit where you can observe, okay to have some distractions

▪ Set up 3 types of stitches, 3 examples

▪ Rapport is critical and how you introduce the screen▪ “Problem solving and following directions”▪ “How you learn best”▪ “Shows how your hands work”

▪ End assessment when pt refuses or if pt is sufficiently stressed

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Scoring

PDF scoring guide available in back of handout

ACL Placemat

ACL Placemat

▪ Only scores 3.0-4.6

▪ Ok to start with placemat before leather lacing to get an idea but always good to follow up with lacing task to confirm score

▪ Placement of shapes - don’t usually complete glueing or fraying edges in order to preserve mat for multiple uses

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ACL Placemat

▪ Place blank mat and complete mat side by side in front of client

▪ Ok to separate shapes for client

▪ Verbal cues/prompts▪ Does that look like mine?▪ There is an error. Can you find it?

ACL Placemat▪ Critical Observations:

▪ Referring to sample

▪ Matching number, location of shapes, rotation, layering hearts

▪ Matching spacing and centering design

▪ Starting work without instructions

▪ moving on to the next step

▪ Asking for help

▪ Requesting to depart from sample

Left-inattention Placemat Example

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ScoringPDF available in back of handout

Small group practice

Questions?

Andrea Betts, OTR/L Julianne Cooper, OTR/L abetts@infinityrehab.com jlcooper@infinityrehab.com

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Thank You