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A Strategic Approach to

Dementia Management Using The Allen Cognitive Level Screen

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What is Dementia? The following is a resource created by Teepa Snow: Dementia Building Skill Handout (p. 1-10)

It is NOT part of normal aging! It is a disease!

It is more than just forgetfulness – which is part of normal aging

It makes independent life impossible

Dementia:

Is an umbrella term that includes many cognitive loss conditions

Includes some reversible conditions – so should be checked out carefully

Alzheimer’s Dementia:

Is the most common type of dementia

is caused by damage to nerves in the brain and their eventual death

has an expected progression with individual variations – about 8-12 years

will get worse over time – we can’t stop it

is a terminal disease – there is NO known cure at this time

Vascular Dementia (multi-infarct):

is caused by damage to the blood supply to the nerves in the brain

is spotty and not predictable

may not change in severity for long periods, then there are sudden changes

Lewy Body Dementia

problems with movement – falls and stiffness

visual hallucinations and nightmares

fluctuations in performance –day to day

Frontal-Temporal Dementias

problem behaviors – poor impulse control

difficulty with word finding

rapid changes in feelings and behaviors

Symptoms common to most Dementias over time:

It affects a person’s entire life. It causes the brain to shrink and stop working

It steals memories – the most recent first, but eventually almost all

It steals your ability to use language. Leaves you with some “skills”

It steals your ability to understand what others mean and say

It steals reasoning and logic

It robs you of relationships

It makes even the familiar seem odd and scary

It steals your ability to care for yourself and move around safely

It robs you of impulse control and takes away emotional and mood control

As part of the disease people with dementia tend to develop typical patterns of speech, behavior, and

routines. These people will also have skills and abilities that are lost while others are retained or

preserved

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The Allen Cognitive Scale is the tool we will be using in order to identify a resident’s abilities,

monitor change over time and help plan treatment for our residence.

The next several pages explain what the Allen Cognitive Test is, how to administer this screen

and how to interpret the results.

Century’s goal is that every patient currently on caseload and all future patients are scored using

this screen at the time of evaluation. If the patient is on more than one discipline, as an

interdisciplinary team you will decide who is going to administer this screen. We will use the

tracker located in the appendix to track scores of each patient. Results from the screen will also

be documented in Optima.

VIDEO INSTRUCTIONS for the Allen Cognitive Level Screen

https://vimeo.com/69276435

***If unable to use leather lacing due to a physical impairment proceed to the RTI-E (Routine

Task Inventory- Extended) located behind this program in order to determine Dementia staging.

https://vimeo.com/69276435

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What is the Allen Cognitive Screen?

Using the Allen Cognitive Level Screen (ACLS) in Dementia Staging

The Allen Cognitive Level Screening is an evidence-based, standardized screening test of functional

cognition designed to provide a quick estimate of cognitive abilities (ability to learn) within cognitive

levels 3, 4, and 5 on the Allen Scale of levels and modes of performance. This scale is a 26- point scale

ranging from 1.0 (low) – 6.0 (high). This provides opportunities to observe current global cognitive

processing capacities related to 1) new learning and problem solving abilities and 2) use of occupational

performance skills. These abilities and skills are observed as they are applied in the performance of three

stitching tasks with a set of carefully designed, standardized activity demands which increase in cognitive

complexity from cognitive level/modes 3.0 to 5.8. As screens, this tool may be used to detect unknown

or suspected problems in functional cognition or to identify potential cognitive abilities. Further

assessment, preferably including observations of performance in meaningful activities, is recommended

to verify the screen score and to provide a more specific and complete understanding of an individual’s

overall level of functional cognitive ability. (Allen, Earhart, & Blue, 1992)

There are Six levels in the Allen Scale: (the following is a very brief description of each level as an

introduction to the Allen Cognitive Levels and Modes of Performance and Level of Care, See Appendix

for “Dementia Stages: Characteristics of Allen Levels (Generalized)

Level 6: independent in daily care, finances and decision-making skills; is comfortable

learning information.

Level 5: independent in daily care; may need assistance with finances, decision making

and organizational skills; may encounter subtle problems with memory; is comfortable

learning new information

Level 4: physically independent with daily care, but needs assistance to initiate or

monitor quality of care; needs increased assistance with all cognitive skills; memory

challenges have increased; may not anticipate possible dangers or consequences; success

is noted with structure and repetition; needs assistance to live in the community

Level 3: Full assistance is required with daily care, including cognitive skills such as

initiating, sequencing, judging, problem solving and decision making; has significant

memory impairment; has difficulty with language and expressing needs, as well as

understanding others; requires 24 hours supervision

Level 2: Dependent on care providers; has significant impairment of all cognitive skills,

including loss of language skills, and a decrease in motor, visual perceptual skills;

requires 24 hour supervision

Level 1: All basic needs must be met by a caregiver

Therapy should be driven by the patient’s best ability to function, not by the impairments or problems that

currently control practice. Therapist should identify the person’s best ability to function and select

treatment goals and methods that maximize those abilities.

The assessment of ability to function is divided into three parts: what the person can do, will do, and may

do. The Allen Cognitive Levels measures what the person can do. The cognitive levels give a general

idea of what to expect from mentally impaired adults. The cognitive levels are stated as ability to

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function. Treatment aims at providing an opportunity for the person to use his or her best ability to

function.

Allen Cognitive Levels of Modes of Performances and Level of Care

Allen, Claudia K., Cognitive Disability and Reimbursement for Rehabilitation and Psychiatry, Journal of Insurance

Medicine 23(4), 1991.

ACL 0: Coma

0.8: Generalized Reflexive Actions

ACL 1: Awareness

Global cognition is profoundly impaired. Person responds to internal cues only. A change in level of

arousal is a specific response to an external stimulus that produce pain or has an instinctive survival

value.

Total Assistance is needed when therapists introduce external stimuli that elicit automatic actions such

as swallowing or looking toward auditory stimuli.

1.0: Withdrawing from Noxious (unpleasant) Stimuli

24-hour nursing care for artificial feeding and turning to maintain skin integrity

1.2: Responding to Stimulation

(Same care as 1.0)

1.4: Locating Stimulation

24-hour nursing care to feed regular diet and initiate rolling bed for skin care

1.6: Rolling in Bed

24-hour nursing care to feed regular diet and initiate rolling bed for skin care

1.8: Raising Body Parts

24-hour nursing care to place cup and spoon in hand and sustain eating, establish route for

voiding, and bathe

ACL 2: Gross Body Movements

Global cognition is severely impaired. Person’s awareness is limited to own postural actions (proprioceptive cues) to move body in space or overcome effects of gravity. There is a lack of

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awareness of the effects that actions have on objects or other people. Maximum Assistance is needed when therapists demonstrate actions or use proprioceptive stimulation to elicit postural actions.

2.0: Overcoming Gravity

24-hour nursing care to transfer from bed to chair, provide food, and do bathroom activities

2.2: Righting Reactions

24-hour nursing care to prevent standing if unable to weight-bear, transfer on sliding board or a pivot transfer, provide food, and do bathroom activities

2.4: Aimless Walking

24-hour nursing care to initiate and assist with all activities of daily living and to prevent wandering and getting lost

2.6: Directed Walking

24-hour nursing care to restrict walking to even surfaces in safe locations such as a room, building, or yard

2.8: Grabbing

24 hour nursing care to stabilize grab bars, rails, furniture, point out stairs, edge of bathtub, provide food, and bathe

ACL 3: Manual Actions

Global cognition is severely impaired. Persons perform spontaneous manual actions in response to tactile cues. Repetitive actions demonstrate an awareness of material objects but lack of awareness of cause and effect, end product, or goal. Attention span is short (maximum 30 minutes) and actions are unpredictable. Moderate Assistance is needed when therapists re-focus attention to sustain/complete simple, repetitive actions safely. One-to-one assistance is required to halt perseveration and to prevent unsafe, erratic, or unpredictable actions that interfere with appropriate sequencing.

3.0: Grasping Objects

24-hour nursing care to elicit habitual motions for activities of daily living and to complete motions for an acceptable level of hygiene

3.2: Distinguishing Objects

24-hour nursing care to place objects needed to do the activities of daily living in front of person and to complete motions for an acceptable level of hygiene

3.4: Sustaining Actions on Objects

Close supervision to place objects needed to do activities of daily living in front of person and sequence through the necessary steps to achieve acceptable results. One caregiver can supervise three persons at a time.

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3.6: Noting Effects on Objects

Close supervision to provide the materials needed for activities of daily living, to remind person to finish necessary steps, to check results, and to remove access to dangerous objects.

3.8: Using All Objects

Close supervision to get materials out that are needed to do activities of daily living, to check results, and to remove dangerous objects.

ACL 4: Familiar Activity

Global cognition is moderately impaired. Person is aware of tangible cues (see and touch) and understands visible cause-and-effect relationships. Goal-directed actions demonstrate an awareness of a familiar end-product but fail to solve new problems, anticipate, or correct mistakes. There is no independent new learning and they cannot invent new motor actions.

They do not recognize errors unless clearly visible, and may request help when mistakes are noticed. Attention span is usually good for up to one hour.

Minimum Assistance is needed when therapists set up goal-directed activities with tangible results. Help is needed to correct repeated mistakes, to check for compliance with established safety procedures, and to solve problems presented by unexpected hazards. Extensive, situation specific training is required to learn new activities, with no expectation for generalization of learned techniques.

4.0: Sequencing

Close supervision to remove dangerous objects and solve any problems occurring through minor changes in routine. Person may fix self a cold meal or snack and make small purchases in the neighborhood.

4.2: Differentiating Features

Close supervision to remove dangerous objects outside of the visual field and to solve any problems arising from minor changes in the environment. Person may spend a daily allowance, walk to familiar locations in the neighborhood, or follow a simple, familiar bus route.

4.4: Completing Goal

Person may live with someone who does a daily check on the environment and removes any safety hazards and solves any new problems. Person may be left alone for part of the day with procedure for obtaining help by phone or from a neighbor. Person may manage a daily allowance and go to familiar places in the neighborhood.

4.6: Personalizing

Person may live alone with daily assistance to monitor personal safety. May manage a daily allowance. Bills and other money management concerns require assistance. Person may require reminders to do household chores, to attend familiar community events, or to do anything in addition to daily household routine.

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4.8: Rote Learning

Person may live alone with daily assistance to monitor safety and check problem- solving methods. Person may get self to a regularly scheduled community activity or succeed in supportive employment with a job coach.

Level 5: Learning New Activity

Global cognition is mildly impaired. The person is able to learn new ways of doing things through trial-and-error problem solving. The person detects the best effect by exploring distinctive properties of objects and trying different actions. They exercise poor judgment with no symbolic thought to plan actions or anticipate potential mistakes. They may make hasty or impulsive decisions or make abrupt changes in their course of action. The determination of what is best may be made according to personal preferences or social standards. The person can imitate a series of new directions; new learning is recognized and repeated during the process of doing an activity.

Standby Assistance is needed when therapists adapt a new activity for safe and effective performance because errors and a need for safety precautions are not always anticipated. Persons may also need memory and planning aids to effectively function at a desired standard.

5.0: Continuous Neuromuscular Adjustments

Person may live alone with weekly checks to monitor safety and check problem-solving methods. Person may succeed in supportive employment with a job coach and get to regularly scheduled valued community activity.

5.2: Discriminating Between Parts of an Activity

Person may live alone with weekly checks to monitor safety and examine potentially dangerous effects of impulsive behavior. Person may succeed in supportive employment with a job coach and participate in valued community events.

5.4: Self-directed Learning

Person may live alone and work in a job with a wide margin of error. Person may not be safe in jobs with a high potential for industrial accidents.

5.6: Considering Social Standards of Context

Person may respond to supervision that identifies hazards occurring as secondary effects of their actions. Person may be relied upon to follow safety precautions consistently.

5.8: Consulting with Others

Person may benefit from assistance in planning for the future. Person may benefit from discussion of complications such as fatigue, joint protections, functional positioning, etc.

ACL 6: Planning New Activity

No global cognitive impairment. Person anticipates errors and plans actions to prevent errors.

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Attention span is defined by desires and priorities. Spoken/written instructions, visual images, diagrams, and drawings are what the person pays attention to. Spontaneous motor actions are preceded with a pause to think. Verbal instructions can be given without a demonstration. Persons consider new information, imagine and reflect on possibilities, reconsider, and exhibit original approaches to task performance. Trial-and-error problem solving may be covert, and “good judgment” is demonstrated. No supervision required. Therapist serves as a collaborative consultant in the treatment process, providing new information to adjust to a physical disability. New motor learning can be done safely and consistently. Hazardous situations are anticipated and avoided, or help is sought when needed. Mobility, communications, and maintenance of adaptive equipment is self-monitored.

6.0: Planning without Objects

Person may consider several hypothetical plans of action and establish abstract criteria for selecting the best plan.

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Structure of the Assessment Manual for the Allen Cognitive Level Screen by C. Allen, S. Austin, S. David, C. Earhart, D McCraith, and L.

Riska-Willaims

The ACLS assessment offers a performance context to view a person’s available cognitive abilities as they are applied to the activity demands of three leather-lacing tasks of increasing complexity. Successful performance of each leather-lacing task implies that the person has abilities that match the required task demands for completing the specified goal of three stitches for each tasks. (p. 8) The task demands span a range of abilities associated with cognitive levels 3 (running stitch), 4 (whipstitch), and 5 (single cordovan stitch) or modes 3.0 to 5.8 on the Allen Scale. They are introduced in order of complexity starting with the simplest task, the running stitch tasks. Complexity is defined by identifying the elements of each task, and comparing them to the sensory cues, motor actions, and problem solving capabilities described in the hypothesized cognitive levels and modes. (p. 9) 1. The Running Stitch: consist of repeating the same action of pushing a threaded needle or lace

through consecutive holes on the leather. https://www.youtube.com/watch?v=_1ouB1Jl34A a. Instructions consist of short statements with simple nouns and verbs accompanying

demonstrations of this repeated action. (see Appendix) b. No additional problems are introduced.

2. The Whipstitch: made by bringing a two-sided leather lace attached to a needle over the

edge of the leather from back to front and pushing the needle in one direction through consecutive holes on the leather.

3. The Single Cordovan Stitch: made by threading the needle and leather lace through a

completed, but not tightened, whipstitch from the front to the back of the leather, and then tightening the whole stich to match a sample stitch

***Detailed Instructions for each stitch located in the Appendix

Administration of the Allen Cognitive Screen

Included in your Allen Cognitive Screen packet are:

1. ACLS-5

2. LACLS-5

3. Understanding Cognitive Performance Mode

4. Scoring Trifold for ACLS-5 and LACLS-5

The following pages describe in detail the administration of each stitch.

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Running Stitch (Level 3.0 – 3.4)

(Person completes 3 correct running stiches in consecutive holes.)

“I am interested in seeing how you follow directions and concentrate”

“Can you see the holes”

“I will show you how to do a stitch now, watch carefully”

“Take the needle. Push it through the next hole. Pull it tight. Push the

needle through the next hole. Pull it tight. Don’t skip any holes. Now you

do it.”

Encouragement for continued Participation – Running Stitch

If person doesn’t attempt: “please make a stitch.”

If person stops before completing 3 stitches: “please make more stitches.”

If person seeks assurance: “Just do the best you can.”

If person doesn’t try after encouragement: Continue to a 2cnd

demonstration.

2cnd Demonstration – Running Stitch

**If an error is made (stitch over edge of leather, skipping a hole, going the wrong

direction, using wrong lace, going in/out of same hole, or stitching in a different

section of the leather, note behavior and allow person time to recognize and

correct error.

Remove incorrect stitches; then:

“Let me show you again.”

Repeat previous demonstration and instructions

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Whipstitch (Level 3.4 – 4.4)

(Person completes 3 correct whipstitches in consecutive holes including

recognizing and correcting the cross –in-back error and the twisted lace error)

“See how the leather lacing has a rough side and a smooth side?”

“Can you tell the difference?”

“Always keep the smooth side up as you do each stitch, and being careful

not to twist the lace.”

“Now I will show you another stitch. Watch me carefully.”

“Take the lace and bring it around to the front, over the edge of the

leather.”

“Push the needle through the hole and tighten it.”

“Make sure the lace isn’t twisted.”

“Don’t skip any holes.”

“Please make 3 stitches.”

Encouragement for continued participation – Whip Stitch

If person doesn’t attempt: “Please make a stitch.”

If person stops before completing 3 stitches: “Please make three stitches.”

If person seeks assurance: “Just do the best you can.”

If person doesn’t try after encouragement: Continue to a 2cnd

demonstration.

***If an error is made (skipping a hole, cross in back error, a twisted lace error, or

more than 3 stitches) note behavior and allow person time to recognize and

correct error.

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Whipstitch Cont.

If the person completes 3 whipstitches without an error, proceed to the

introduction of Errors.

If the person makes the cross in back and twisted lace error and recognizes and

corrects the error; proceed to the Cordovan Stitch.

If only one error is made and corrected; proceed to Introduction in Error for type

of stitch error not completed

If the person makes errors and doesn’t recognize and correct errors, then note

behavior and proceed with the following:

Interventions for Errors – Whipstitch

“Do your stitches look like mine?”

“If answer is “NO”: “Please try to fix them.” Allow time to correct

If person recognizes and corrects the cross in back and twisted lace

error, move to Single Cordovan

If person completes 3 Whipstitches, but does not recognize and

correct either the cross –in –back or twisted lace error, then continue

to problem solving whipstitch errors

If person attempts to recognize and attempts to correct are not

effective : Go to 2cnd Demonstration

If answer is “YES”: “There is a mistake, please try to find and fix it.”

Proceed as listed above based on person’s response.

2cnd Demonstration

Remove incorrect stitches; then

“Let me show you again.”

If correct: Proceed to Single Cordovan Stitch

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Whipstitch Cont.

If completes 3 or more whipstitches in consecutive holes and recognizes

but unable to correct –in –back or twisted lace error, continue to problem-

solving whipstitch errors

If person’s attempts to recognize and correct errors do not appear

effective: continue to problem-solving whipstitch errors

Instructions for introducing the 2 errors (cross stitch and twisted leather) are as

follows:

Cross –in –back error:

“I’m going to make a mistake to see if you can correct it?”

The administrator takes the ACLS and holds it out of sight of person

Bring needle over edge of leather to front and pushing it from front to back

through next hole

On the backside of the ACLS, push the needle through the loop trapping the

lacing underneath the loop (this forms a cross in back of the ACLS)

Hand the ACLS back to the person

“Please show me my mistake? Please try to fix it?”

If seeks assurance: “Just do the best you can.”

Whether or no person recognizes and corrects cross –in –back error, No

additional cues are given.

If person was observed recognizing and correcting a twisted lace error;

proceed to single cordovan stitch

If the person has not already been observed recognizing and correcting a

twisted lace error; introduce the twisted lace error.

Twisted lace error:

“I’m going to make a mistake to see if you can correct it.”

The administrator takes the ACLS and holds it out of sight of person

The administrator takes the ACLS and introduces two twists in the last 2

stitches. Make the twist clearly visible. Hand the ACLS back to the person

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Whipstitch Cont.

“Please show me my mistake? Please try and fix it?”

If seeks assurance: “Just do the best you can.”

If person removes lace to correct error: “Please correct the mistake without

taking the lace out of the hole.”

Whether or not person recognizes and corrects twisted lace error without

removing lace from hole; if person was able to correct at least one error;

continue to single cordovan stitch.

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The Single Cordovan Stitch (Level 4.20 – 5.8) (Person completes 3 correct single cordovan stitches in consecutive holes)

“Please make 3 stitches without me showing you how to make them. If you

cannot figure it out, I will show you.”

Encouragement for continued participation – Single Cordovan Stitch

If person doesn’t attempt: “Please make a stitch.”

If person stops before completing 3 stitches: “Please make more stitches.”

If person seeks assurance: “You are making progress,” “This stitch is hard,”

This is a difficult tasks,” “Most people try different things,” or “Just keep

trying.”

If person specifically asks “Is my Stitch correct?” “I’d like you to decide” or

“I need to see what you can do without my help.”

If, after encouragement, person does not correct errors (Such as going through

hole or loop the wrong way, directing needle to wrong side of lace, tightening in

wrong sequence, or completing two whipstitches) or person appears overly

anxious or frustrated: “Would you like some help?” or “Would you like a hint?”

If person says “No” and continues to try to solve problem:

Allow person more time and correctly completes: end assessment

If problem-solving behavior continues to be ineffective: offer 1st

demonstration

If person says “Yes” continue to one verbal cue

Provide One Verbal Cue

“You have the first part right,” “Look at how you are going through the

hole,” or “Is there another way you can go through the loop?” “Is there

another way to tighten the lace?”

“If person completes the stitch: end the assessment

“If person attempts are ineffective, ask: “Would you like me to show you

how?”

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The Single Cordovan Stitch Cont.

If answer is “No” Allow more time

If ineffective: Offer 1st demonstration

If answer is “Yes” Continue to 1st demonstration

Provide 1st Demonstration

“Watch me carefully”

“Bring the needle to the front of the leather.” “Push the needle through the

next hole from front to back.”

“Don’t pull the lacing tight but leave a small loop in it.”

“Bring the lace to the front of the leather; this time put the needle through

the loop, you have made.”

“As you go through the loop, keep the needle to the left of the lace.”

“Pull the lace through the loop. Tighten the stitch by pulling the lace from

the back, and then by pulling the long lace end.”

“Make sure the lace isn’t twisted. Please do 3 stitches.”

Encouragement for continued participation – Single Cordovan Stitch

If person stops before completing 3 stitches: “Please make 3 stitches”

If person seeks assurance: “Just do the best you can”

If person does not try after encouragement: End assessment

If person attempts; but is ineffective: ask “Would you like me to show you

again?”

If “No” end the assessment

If “Yes” continue to 2nd demonstration

2cnd Demonstration

Remove incorrect stitches and say “Let me show you again.”

Repeat instructions and encouragement as in 1st demonstration

End Assessment when:

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The Single Cordovan Stitch Cont.

Person completes 3 correct single cordovan stitches in consecutive

holes, or

Person does not complete 3 correct single cordovan stitches in

consecutive holes, and person’s problem-solving behavior, as

evaluated by administrator, continues to be ineffective, or

Person asks to end screening assessment

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Interpretation of the Allen Cognitive Screen

Screen scores will be assigned from the table provided in the ACLS-5 manual.

These can serve as an estimate for the individual’s cognitive level and mode.

Mode provides the behavioral description of the score. Document the screening tool that was used and the score obtained.

This information will allow therapist to perform additional assessments to confirm this estimate.

Once a mode is determined, this information is integrated with the person factors that are unique to the client to establish goals and an intervention plan.

***See scoring tables in Appendix ***In your packet is “Understanding Cognitive Performance Modes” by Claudia Key Allen, MA. OTR, FAOTA, Tina Blue, OTR and Catherine A Earhart, OTR. This book gives detailed descriptions on each cognitive mode, the patient’s abilities, Functional goals, therapist goals, and treatment methods. Please refer to this book for further information

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Appendix

1. Dementia Stages: Characteristics of Allen Levels (Generalized)

2. Memory Aid

3. Summary of Allen Cognitive Modes

4. ALCS Tracker

5. Table 1: Scores for Running Stitch Task

6. Table 2.1 Scores for Whipstitch Task

7. Table 2.2 Scores for Whipstitch Task

8. Table 3.1 Scores for Single Cordovan Stitch Task

9. Table 3.2 Scores for Single Cordovan Stitch Task

10. Table 3.3 Scores for single cordovan Stitch Task

11. Caregiver Guide

12. Caregiver Guide

13. Caregiver Guide

14. Caregiver Guide

15. Caregiver Guide

16. Allen Sensory Diet Guide

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Dementia Stages:

Characteristics of Allen Levels 4, 3, 2 (Generalized)

Allen Level 4 (Early Stage Dementia)

Allen Level 3 (Middle Stage Dementia)

Allen Level 2 (Late Stage Dementia

General Description:

Completes approx.. 75% of self-care Poor attention to detail (req. VC) May not comb back of head, may not

change undergarments, mixes plaids and flowers)

Social butterfly (enjoys social activities: Bingo, outings, etc.)

Sequences routine but no set-up or clean-up

Poor safety “Talks the talk, bud does not walk the

walk” Will fool you every time!

Random actions with only partial task completion

Requires constant cues to complete self-care

Likes to “fiddle” with hands (constantly)

Confused/Wanders

May eat ½ of meal then become distracted and/or play with food

Follows only one step directions

Communicates in short phrases

Focus is on basic needs and potential actions

Fear of falling especially anteriorly – noted to demonstrate posterior weight shift

Easily agitated if rushed

Cognitively with processes 2-3 times slower

Disrobes with somatic complaints/discomfort

Tends to wander (agitated with confinement)

Follows people or goes where directed

High: Oriented to person, place and time

Can read instructions (with errors)

May “live alone” if no stove (“couch potato” is best)

Able to learn about 3-4 steps but without safety component

Learns destination or a previously learned tasks after about 3 weeks of consistency

Performs tasks without completion

Needs verbal cues to the next step in a sequence

Death grip on rails (decreased volitional release of grasp)

Will walk to an identified location

Consumes found food

Low: Oriented to person, place and Routine

May be cued to a calendar

Tends to like structure and schedules

One minute attention span

Visual field reduced to 12-14 inches

Needs constant cueing to remain engaged in a tasks

Challenge is overcoming gravity

Slumped posture, downward gaze

One word communication

Responds well to reciprocal movement patters and sing-song method

Treatment Considerations:

Needs consistency/structure with routine for increased safety

Structure the environment to make them safer

Establish schedules, lists, memory devices

Train to prevent falls NOW before dementia progresses to lower levels

Prevent weight loss (poor attention during meal times)

Behavior may become an issue if cues are not appropriate or if task is too difficult

Focus on staff training for FMP or RNP

Focus on staff training for methods to cue resident using visual, tactile, verbal cueing (slow… patient requires 2-3 times longer to process cues

Prevention of falls, positioning issues, combativeness, contracture formation

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Memory Aid Allen Cognitive Training Resource Manual

Dementia Stage ACL LEVELS

ACL MODES with % for Cognitive Assistance

End Stage 1.0 Withdrawal from stimuli 100% 1.2 Respond to Stimuli 100% 1.4 Locate Stimuli 96% 1.6 Moving in bed 96% 1.8 Raise body parts 88%

Late Stage 2.0 Overcome gravity 84% 2.2 Stands and use righting action 82% 2.4 Walk 78% 2.6 Walk to identified location 74% 2.8 Use railing and grab bar for support 70%

Middle Stage 3.0 Grasps objects 64% 3.2 Distinguishes between objects (sorts) 60% 3.4 Sustains actions on objects (repeats) 54% 3.6 Notes effects of actions on objects 50% 3.8 Use all objects and senses completion 46%

Early Stage 4.0 Sequence self-thru steps of activity 42% 4.2 Differentiate parts of an activity 38% 4.4 Complete a goal 34% 4.6 Scan the environment 30% 4.8 Memorize new steps 26%

Mild Cognitive Impairment

5.0 Learn to improve the effects of action 22% 5.2 Improve the fine details of actions 18% 5.4 Engage in self-directed learning 14% 5.6 Consider Social Standards 10%

Normal 5.8 Consult with other people 6% 6.0 Planned activity 0%

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Summary of the Allen Scale Modes of Performance Claudia K. Allen MA OTR FAOTA

Mode Description Pays Attention to Motor Control Verbal Communication by

1.0 Withdrawing from Stimuli Inborn Sensory Stimulus Inborn Withdrawal Inborn Non-Verbal Utterance

1.2 Responding to Stimuli Strong Sensory Stimuli

Any 1 of 5 Senses Eyes, Nose, Mouth Selective, Non-Verbal Utterance

1.4 Locating Stimuli Being Fed, Moving Sensory Stimuli Head Turning, Tracking, Swallowing

Non-Verbal Expression

1.8 Moving in Bed Moving Trunk, Limbs Head, Trunk, Legs, Arms Non-Verbal Expression

2.0 Raising Body Parts Buttocks Pivot Transfers Saying “No”

2.2 Protecting Self Comfort of Gross Body Movements Sitting Saying “Yes” or “No”

2.4 Overcoming Gravity Security of Gross Body Movements Standing, Righting Reaction

Naming Parts of Body

2.6 Standing and Righting Reactions Freedom of Movements Walking, Directing Movements

Using One Word to Start Communication

2.8 Walking Location of Freedom of Movements Following Gross Motor Demonstration

Singing

3.0 Walking to an Identified Location Balance Hanging on Tight, Hitting, Kicking

Naming Target

3.2 Using Railings, Grab Bars Handling Material Objects Hands Using Nouns and Verbs

3.4 Grasping Objects Moving Objects Back and Forth Hand Movements Using Short Phrases

3.6 Distinguishing between Objects Repeating Action Placing Objects in a Row Remembering Current Action

3.8 Sustaining Actions on Objects Effects Actions Have on Objects Following Demonstrated Effects

Remembering for a Minute

The intellectual material in this document is copyright 1995 by Claudia Allen, MA OTR FAOTA. Permission to reproduce this material is given to people who

received the material from Claudia Allen or the Allen Cognitive Group.

24

Summary of the Allen Scale Modes of Performance Claudia K. Allen MA OTR FAOTA

Mode Description Pays Attention to Motor Control Verbal Communication by

3.8 Sensing Completion Effects of Actions on an Activity Sequencing Actions Recognizing Activity Only when Done

4.0 Sustaining a Short-Term Goal Activity to be Done Doing Routine Activities Remembering Current and Past

Activities/Possessions

4.2 Differentiating between Parts of Activity

Part of a Simple Activity Matching 1 Striking Cue Following Social Rituals Inflexibly

4.4 Completing a Goal Pairs of Striking Cues Matching 2 Striking Cues at a Time

Follow Social Norms Inflexibly

4.6 Scanning the Environment Scanning for Striking Cues Making Activities Pleasing to Self

Expressing Personal Identity

4.8 Memorizing New Steps Steps of New Learning with Striking Cues

Rote Learning to Please Others

List Information to Guide Behavior

5.0 Learning to Improve the Effects of Actions

Improving Effects by Changing Actions Adjusting Fine Motor Actions

Using Speech to Show Feelings

5.2 Remembering How to Improve Fine Details of Actions

Improving the Effects of Surface Properties

Making Simultaneous Fine Motor Adjustments

Classifying Objects and Time

5.4 Engaging in Self-Directed Learning

Improving the Effects of Spatial Properties

Fine Motor Actions in Small Spaces

Tracking in Singular Theme in a Story

5.6 Considering the Needs of Others Anticipating Surface Properties Varying Pace Forming Bonds with Others

5.8 Consulting with Others Anticipating Spatial Properties Designing Patterns, Engaging in Skilled Work

Being Tactful

6.0 Planning Actions Abstract Cues Forming Hypothetical Actions

Collaborating and Using Abstract Thought in Work

The intellectual material in this document is copyright 1995 by Claudia Allen, MA OTR FAOTA. Permission to reproduce this material is given to people who

received the material from Claudia Allen or the Allen Cognitive Group.

25

Table 1 Scores for Running Stitch Tasks Score Rating Criteria

(Observations required for Score) Frequent Observations (Not Required for Score)

Hypothesized Abilities

Less than 3.0

Does not reach for or actively grasp leather or needle or shoelace Fingers may Close around leather when it is placed in person’s hand

Grasp is not associated with objects

3.0 Activity reaches for and grasps leather/needle (ACLS-5) or leather/shoelace tip (LACLS-5) OR Actively pushes leather away and does not grasp needle (ACLS-5) or shoelace tip (LACLS-5)

May grasp leather and needle/shoelace tip and move needle/shoelace tip in random fashion OR May grasp leather and needle/shoelace tip and aim needle/shoelace tip toward a hole

Associates grasp with an object separate from self

3.2 Pushes needle/shoelace tip completely through at least one hole anywhere on leather

May push needle/shoelace tip through two or more holes which are not consecutive

Associates object with particular manual actions Coordinates eyes and hands to execute a particular action

3.4 Completes at least 3 running stitches in consecutive holes with any of the three laces. These stitches may be anywhere on the leather

Repeats a prompted manual action of interest Reverses direction of an action Perceives row/line Moves in a direction (left-right)

Manual for Allen Cognitive Level Screen -5 (ACLS-5) and Large Allen Cognitive Level Screen -5 (LACLS-5)

Allen, Austin, David, Earhart, McCraith, Riska-Williams

26

Table 2.1 Scores for Whipstitch Task Score Rating Criteria

(Observations required for Score) Frequent Observations (Not required for Score)


3.4 Completes only 1 Whipstitch going from front to back of leather OR Completes 1 or more stiches that go over the edge of the leather from back to front

When asked to find and fix their mistakes, does not find visible twisted lace and/or cross-in-back-errors

May revert to making running stitches

May recognize a running stitch error on front of leather as not the same as sample stitch

Fleeting ability to approximate a two-step action sequence

Fleeting association of 2 mismatched cues

Beginning sense of error recognition

3.6 Completes at least 2 whipstitches in consecutive holes going from front to back of leather

Stops before all holes are filled or lace is used up

Recognizes a running stitch error on front of leather as not the same as example stitch

When asked to find and fix their mistake, does not find visible twisted lace and/or cross-in-back-errors

Briefly associates cause and effect for a two-action sequence

Aware of being led/instructed by another person

3.8 Completes multiple whipstitches in consecutive holes going from front to back of leather until all holes are filled or lace is used up OR Completes at least 3 whipstitches in consecutive holes, stops before all holes are filled or lace is used up, and may show uncertainty about being “done”

When asked to find and fix their mistake, does not find visible twisted lace and/or cross-in-back errors

May make brief attempts to correct stich errors on front of leather

When asked to find and fix their mistake, does not find running stitch errors on back of leather

Sustains cause and effect for a two-action sequence

Beginning sense of completion

Sense of completion is cued by material objects



27

Table 2.2 Scores for Whipstitch Task Score Rating Criteria



4.0 Completes at least 3 whipstitches in consecutive holes and stops before all holes are filled or lace is used up, indicating they are “done”

When asked to find and fix their mistake, finds at least one visible twisted lace or cross-in-back error

Does not attempt to correct visible twisted lace or cross-in-back errors

When asked to find and fix their mistake, finds and corrects running stitch errors on back of leather

Recognizes a completed stitch as sample or goal to be achieved

Compares own stitch to sample stitch

Recognizes a striking error

4.2 Completes at least 3 whipstitches in consecutive holes

When asked to find and fix their mistake, finds all visible twisted lace errors

Corrects visible twisted lace errors by removing entire stitch

Fails to fix a twisted lace error without removing stitch

May stop after completing 3 whipstitches OR May complete more than 3 whipstitches, but when asked, states that only 3 stitches have been made

May recognize and correct a cross-in-back error spontaneously

Associates actions with a particular feature (twist or cross-in-back)

Undoes or reverses simple actions just done to solve an identified problem

4.4 Completes at least 3 whipstitches in consecutive holes

Recognizes and corrects all cross-in-back errors spontaneously

Recognizes and corrects all visible twists spontaneously

Corrects at least one twisted lace error spontaneously or when requested without removing stitch

Stops after completing 3 whipstitches OR May verify that 3 stitches are required while working, or after completing, 3 stitches

Oriented to top and bottom of objects

Flips or turns objects to solve a problem

Oriented to prescribed order or sequence of events



28

Table 3.1 Scores for Single Cordovan Stitch Task Score Rating Criteria



4.2 Does not complete 3 correct single cordovan stitches in consecutive holes after 2 demonstrations

Makes repeated whipstitches OR Makes 1 whipstitch followed by an error, such as going through same hole twice, or making a running stitch

Does not recognize errors OR Recognizes error(s) but does not attempt to correct OR Recognizes and attempts to correct error by reversing only last action performed

Is likely to decline offer of a second demonstration

Replicates one or two actions of a longer sequence of actions

Undoes or reverses actions just done to solve a problem


Makes a whipstitch and immediately pushes needle through loop from back as if it were 1 step. Lacing is under, but not wrapped around, loop OR Pushes needle through hole from back to front and through loop from front to back

Does not recognize incorrect stitch OR Attempts to correct an identified error by removing entire stitch and repeating unsuccessful methods

May decline offer of a second demonstration

Chunks sequences exceeding two actions (first part, lace through hole; second part, lace through loop)

Oriented to top and bottom of objects

Flips or turns objects to solve a problem

Oriented to prescribed order or sequence of events


Pushes needle from front to back through hole and loop and then pushes needle through loop twice or through next hole. Stitch is not tightened OR Pushes needle from front to back through hole and loop with needle to right of lace as it exist from back of hole. Stitch is not tightened

Does not recognize errors OR Attempts to correct identified errors by removing stitch and varying direction in which needle is pushed through holed and/or loop

Accepts offers second demonstration

Performance does not improve after second demonstration

Replicates up to four actions of a longer sequence of actions

Shows beginning awareness of third dimension

Orients to position of objects in space relative to self



29





Pushes needle from front to back through holes and loop, and then pulls on lace end to tighten stitch. Does not tighten stitch in demonstrated sequence

Does not direct needle consistently to right or left of lace while pushing it through loop

Does not recognize errors OR After close examination of an incorrect stitch, expresses uncertainty about whether or not stitch is incorrect

Attempts to correct identified errors by pulling harder on lace or by varying direction of pull on lace


Replicates up to 4 actions and last action of longer sequence or action

Varies pressure and angle of motor actions to solve a problem


Pushes needle from front to back through hole and loop. Tightens stitch by pulling on lace in various ways from front and back of loop. Does not tighten stitch in demonstrated sequence

Spontaneously recognizes errors

Attempts to correct identified errors one at a time by changing methods of untwisting, untangling, and tightening lace

Discovers successful solutions but does not repeat these solutions to complete subsequent stitches


Initiates multiple variations of actions to solve problems (trial and error)

Executes flexible and fluid manual actions on objects



30




5.2 Completes 3 correct single cordovan stitches in consecutive holes after 2 demonstrations

Pushes needle from front to back through hole and loop and tightens stitches by pulling on lace demonstrated sequence

Discovers successful solutions to correct errors; repeats solutions to complete subsequent stitches

Performance improves after second demonstration

Understands a complex visual cue (completed stitch)

Notices demonstrated secondary effects (tightening sequence)

Recalls demonstrated sequence of 6 to 7 actions after several minutes

Recalls discovered solutions after several minutes

5.4 Completes 3 correct single cordovan stitches in consecutive holes after 1 demonstration

Pushes needle from front to back through hole and loop; tightens stitches by pulling on lace in demonstrated sequence

Tightens lace so tension matches sample stiches

Continues to vary actions until 3 correct single cordovan stitches are completed

Instructions are understood as a unit with parts

Notices visible secondary effects of own actions

Recalls own methods and compares with demonstrated instructions to identify part(s) with error

Makes effective fine motor adjustments

5.6 Completes 3 correct single cordovan stitches in consecutive holes after 1 orienting verbal cue

Solves a problem with 1 orienting verbal cue

Corrects all other errors independently

Interprets and uses verbal cues to solve new problems with objects

5.8 Completes 3 correct single cordovan stitches in consecutive holes without an orienting verbal cue or a demonstration

Corrects all errors independently

Inferences are made to solve new problems with objects



31

Allen Cognitive Screen Tracker

Patient Name Date Current Level

Patient Name Date Current Level

32

OCCUPATIONAL THERAPY LEVELS 2.4 –2.8 CAREGIVER GUIDE

Allen Cognitive Level Screen (ACLS): Date/Time screened: Screened by:

The Allen Cognitive Level Screening (ACLS) is a standardized measurement of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The occupational therapy recommendations listed below are suggestions for the caregiver and are meant to facilitate the best ability to function within the least restrictive environment.

Requires 24 hour close on site supervision

Prevent the tendency to resist care by allowing extra time for everything A consistent environment and routine is recommended

Communicate using clear and concise statements

Medication Management

Caregiver must assume all responsibility since the patient is unable to understand necessity, timing, or side effects.

Nutrition

Caregiver must provide total set up and assume all responsibility for dietary restrictions/provide a balanced diet, and offer liquids frequently.

Monitor swallowing:

Follow all swallow precautions: positioning, texture of foods, cut food into small pieces.

Monitor that medications are completely/appropriately swallowed.

Feeding: Use verbal and demonstrative cues to prompt to continue eating. May require being fed all or most of meal. Remove small non-edible items from reach. Use a bib or towel to prevent clothing from becoming dirty. Prevent burns by monitoring the temperatures of drinks within arm’s reach. Prevent spills by filling cup partially full or use of a lid/straw.

Bathing

Verbally cue and/or use hand over hand assistance, as needed. Use tub bench for showering to prevent falls. Install grab bars, tub mat, hand held shower and cues/assist to use.

Dressing

Dress in a seated position to prevent falls and the possible fear of falling. Cue to move body part/limb during dressing and rehearse naming each body part.

33

Safe and comfortable footwear will help to prevent falls.

Toilet Use

Assist and cue to use toilet every two hours and 30 minutes after meals and to the location of the toilet.

Personal hygiene requires assistance.

Mobility and Positioning Provide safe space to wander within range of visual supervision. Recommend active or passive range of motion exercises one or more times per day to

prevent muscle weakness, contractures and loss of range.

Remind and assist with any equipment required for safe ambulation: walker, cane-as often as necessary.

Proper positioning may improve posture & cognition, and helps to prevent sores. Use seat cushions/wedges to position correctly & prevent slipping or slouching. Use a lap tray, as appropriate. Transfer safety: use a count of three and verbal and/or physical cues for where to place

hands and/or feet.

Safety

Barricade open stairwells, use intercom, and install security doors or locks. Leave bed side-rails down to prevent climbing over and/or falling. Perceptually they may require cues for barriers below the knee (steps, curbs, roots, items

on floor, side of tub, coffee table), or may be overly aware of floor patterns.

Remove unsteady furniture or bathroom towel racks they may grab onto for support. Install proper/safe handrails and cue to use.

They may grab onto things and have difficulty letting go of objects. Offer something else to hold (face cloth).

Offer soft object(s) for patient to hold if they tend to hit, scream or kick –remember this is often a sign of gravitational insecurity.

Leisure/Environment

Include pleasurable and enjoyable experiences every day. Music: favorite songs, singing, and movement are often enjoyed. Multi-sensory

engagement is often successful. Provide assisted activities for movement or active assisted range of motion daily. May enjoy walking . Provide a calm but sensory rich environment It is important to determine the types and amounts of stimulation the person is able to

tolerate at different times of the day and to prevent sensory deprivation.

***Refer to enclosed “sensory diet” form for additional recommendations.

Reference

Allen, C.K., Blue, T., & Earhart, C. (1995). Understanding Cognitive Performance Modes. Ormond, Florida: Allen Conferences. Compiled by: Tina Champagne M.Ed., OTR/L Allen Authorized Advisor ~ 12/2003 rev

34

OCCUPATIONAL THERAPY LEVELS 3.0 – 3.4 CAREGIVER GUIDE


The Allen Cognitive Level Screening (ACLS) is a standardized measurement of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The occupational therapy recommendations listed below are suggestions for the caregiver and are meant to facilitate the best ability to function within the least restrictive environment.

Requires 24 hour on site supervision

A consistent environment and routine are recommended.

Communicate using clear and concise statements

Medication Caretaker must assume all responsibility since the patient is unable to understand

necessity, timing or side effects.

Observe client when swallowing medications to assure they are taken as directed.

Eating

Provide a balanced diet and monitor for compliance with any dietary restrictions. Use verbal cues to prompt to continue eating when necessary. Prepare and place food in front of the client and assist by cutting foods and opening

containers as necessary. Feeding requires . Prevent burns by monitoring the temperatures of drinks within arm’s reach. Prevent spills by partially filling cup or using a lid/straw. Remove small non-edible items from arm’s reach.

Dressing and Hygiene

Prompt and assist as needed when it is time to dress and wash, use of a seated position may reduce the risk of falls.

Place clothing in plain sight and in the order to be put on with assistance provided as needed.

Prompt or assist if putting clothes on inside out or backwards. Prompt or assist to wash hands and adjust clothing after toilet use. Place toiletries in plain sight and use verbal/hand-over-hand prompts for each step. Allow the client to take an active part in dressing and hygiene if possible–providing

physical assistance as needed.

Toilet Use

Assist and cue to use toilet every two hours, and 30 minutes after meals. Personal hygiene requires assistance.

35

Safety recommendations

A safe environment and close monitoring is needed. Place name on door of bedroom, particularly when in new environments. Barricade open stairwells & install gates, especially at night. Intercom systems, night-

lights, security doors or locks may prevent wandering and/or getting lost. Leave bed side-rails down to prevent climbing over. A tub bench or seat, grab bars and a hand-held shower often help to prevent falls. Monitor temperature of water to avoid scalding & assist in and out of shower. Remove unsteady furniture patient may grab onto for support, small rugs, and

objects on floor, especially in the bathroom. Lock away medications and toxic chemicals or keep out of reach. Supervise closely when near the stove (may touch a hot burner).

Mobility and Positioning Recommend active &/or passive range of motion exercises one or more times per day, to

prevent muscle weakness, contractures and/or loss of range.

Remind and assist with all use of any equipment required for safe ambulation: walker, cane-as often as necessary.

Proper positioning often improves posture, cognition and helps to prevent sores. Use a lap tray or seat cushions/wedges to position correctly & prevent slipping or

slouching as appropriate. For transfer safety and awareness: use a count of three, verbal and physical cues.

Activities

Encourage engagement in an activity to prevent sitting for extended periods. Set the person up with repetitive tasks. Place objects directly in front of the person. Provide limited choices and fully set up the activity. Demonstrate each step and provide cues to “keep going”. Provide a place to sit and watch the activities of others. Provide a calm environment: consider lighting, sound, amounts and types of

stimulation.

Encourage movement (e. g., routine walks, simple stretches – as appropriate) It is important to determine the types and amounts of stimulation the person is able to

tolerate at different times of the day and to prevent sensory deprivation.


Reference

Allen, C.K., Blue, T., & Earhart, C. (1995). Understanding Cognitive Performance Modes. Ormond, Florida: Allen Conferences.

Compiled by: Tina Champagne M.Ed., OTR/L Allen Authorized Advisor ~ 12/2003 rev

36



The Allen Cognitive Level Screening (ACLS) is a standardized measurement of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The occupational therapy recommendations listed below are suggestions for the client and/or caregiver and are meant to facilitate the best ability to function within the least restrictive environment.

Requires 24 hour on site supervision

Communicate using clear and concise statements Transportation

must be provided, as needed

Medication

Caregiver must assume all responsibility since the patient is unable to understand necessity, timing or side effects.

Observe when swallowing medications to assure they are taken as directed.

Nutrition

Provide a balanced diet and monitor that meals are eaten, fluids are taken in regularly and that any dietary restrictions are followed.

Prepare and place food in front of the person and assist by cutting foods and opening containers as necessary. Feeding requires .


Prompt when it is time to dress and wash.

Prompt to wash hands and adjust clothing after toilet use, provide assist if needed.

Place toiletries in plain sight; they may not look for objects. Give verbal prompts for each step in sequence.

Place clothing in plain sight and in the order to be put on.

Allow the client to take an active part in dressing and hygiene and provide assistance as needed.

Remember the person may not ask for help or recognize the need for it.

37

Safety recommendations

A safe environment and close monitoring is needed.

Place name on door of bedroom, particularly when in new environments.

Barricade open stairwells and install gates, especially at night. Intercom systems, night-lights, security doors or locks may prevent wandering and/or getting lost.

Leave bed side-rails down to prevent climbing over.

Assist in and out of shower to prevent falls.

A tub bench or seat, grab bars and a hand-held shower are often useful.

Bathing and dressing from a seated position may help those at risk for falls.

Monitor the temperature of water to avoid scalding.

Remove unsteady furniture as the person may grab onto it for support, especially in the bathroom.

Small rugs and objects on the floor create increase the probability for falls.

Medications and toxic chemicals should be kept locked out of reach.

Supervise closely when near the stove (may be impulsive and touch hot burner).

Activities

Encourage engaging in meaningful activities to prevent sitting for extended periods of time.

Provide daily social opportunities and facilitate engagement when needed.

Use repetitive tasks (polishing, sanding, folding) or basic crafts/activities.

Place objects directly in front of the person.

Give limited choices and fully set up the activity.

Demonstrate each step and provide cues to “keep going”.

Allow extra time for all activities due to slow pace.

Provide a place to sit and watch activities of others.

Provide calming environment: consider lighting, sound, and amount of stimulation.

Encourage daily activities providing range of motion/movement (e.g., routine walks or simple seated stretches when appropriate).

Provide a calm yet sensory rich environment to prevent both over-stimulation and/or sensory deprivation.

Music and singing are often enjoyed, particularly music that is meaningful or from the person’s era.


Reference



38



The Allen Cognitive Level Screen (ACLS) is a standardized assessment of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The occupational therapy recommendations listed below are suggestions for the client and/or caregiver, and are meant to facilitate the best ability to function within the least restrictive environment.

RECOMMEND 2 4 – H O U R SUPERVISION

Driving is not recommended – transport is required Allow

extra time for all activities due to slow pace

Medication

Caregiver must assume all responsibility for administration and monitoring of effects. Observe client when swallowing medications to assure they are taken as directed. The client may not recognize the need to take medications and may require

continued reminders/education.

Nutrition

Assistance to assure a balanced diet is consumed and the following of any dietary restrictions is strongly recommended.

Meal planning, shopping and cooking require assistance, and are not recommended unless close supervision and assistance are provided as needed.

Safety

The client may underestimate or inconsistently anticipate potential hazards within their environment. Therefore, caregiver must provide frequent safety checks to the environment.

Recommend set up of home/environment to promote safety: o Installation of tub bench or seat, grab bars and a hand held shower o Adjust hot water thermostat to avoid scalding. o Remove unsteady furniture, small rugs and objects from the floor. o Supervise closely when around the stove or appliances. Appliances with

automatic shut-off may be helpful.

o Medications and all toxic chemicals are best kept out of reach. o Frequently review safety rules and routines: (e.g., wet floors, no smoking in bed, use of

hand-rails and grab bars, fire escape routes, use of med-alert equipment).

o Lock away all power tools & guns. Close supervision is recommended with pet or childcare.

39


Reminders may be required to wash & dress appropriately, and may attempt to wear the same clothing every day.

Place toiletries & clothes in the same location and in plain sight, whenever possible. Allow client to gather items and assist for sequencing and hygiene if needed. Provide verbal prompts to attend to details (e.g., combing hair on back of head,

aligning buttons, zipping zippers or avoiding the over use of cosmetics/cologne). Allow extra time and encourage a daily routine. Remind and provide appropriate clothing for changes in weather. Remind and provide sunscreen, especially if medications increase skin sensitivities. Laundering clothing often requires assistance.

Money and Time Management

Establish and help to maintain a balanced daily routine. Use of a large calendar in plain sight is recommended, although consistent use will require ongoing assistance.

Involve in familiar household tasks with one-step verbal instructions. Facilitate the inclusion of meaningful leisure activities into one’s daily routine. Money management may require complete or close supervision.

Learning Strategies

Verbal skills are often better than actual task performance abilities, and may be deceiving.

Provide cues to assist with focusing on the present task. Teach tasks using demonstration, verbal instruction, slow pace, and repetition – one step at

a time.

Practice safety routines and tasks frequently Assistance is required to sequence though the steps of activities, particularly when novel.

Learning within one environment does not guarantee the ability to generalize to another. Therefore, when in new situations or environments provide assistance.

Avoid giving directions over the phone or in writing. Allow the client to experience cause & effect as appropriate. Remember that they may only recognize immediate and concrete consequences of

actions and will require assistance for realistic planning and goal setting.


Reference



40



The Allen Cognitive Level Screen (ACLS) is a standardized assessment of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The occupational therapy recommendations listed below are suggestions for the client and/or those providing assistance and are meant to facilitate the best ability to function within the least restrictive environment.

To live alone in the community, the following is recommended within a safe environment with well-established routines and rehearsed safety plans:

Daily Supervision

Weekly Supervision

Transportation

o Assistance is required to determine the most realistic, safe and functional transportation option(s)-and to assure set up/availability.

o Alternative transportation options may include .

Medication

Provide supervision for accurate medication management and monitoring of effects.

Assistance for recognizing the ongoing need to take medications may be required; ongoing reminders and education are often helpful.

o Additional recommendations: .

Nutrition and Cooking

Assistance to assure the following of any dietary restrictions is strongly recommended.

Balanced meal planning, shopping and cooking require assistance. Use of appliances with automatic shut-off may be helpful.

Safety

The client may underestimate or inconsistently anticipate potential hazards within their environment. Therefore, recommend frequent safety checks to the environment.

Recommend set up of home/environment to promote safety:

o Installation of tub bench or seat, grab bars and a hand held shower.

41

o Adjust hot water thermostat to avoid scalding.

o Remove unsteady furniture, small rugs and objects from the floor. o Frequently review safety rules and routines (e.g., wet floors, no smoking in bed, fire

escape routes).

o Supervise the use of power tools and/or heavy equipment.

Supervision is recommended for pet or childcare.


Reminders may be required to wash & dress regularly/appropriately.

Verbal prompts for attention to details may be required.

Remind to use sunscreen, especially if medications increase skin sensitivities.

Laundering clothing may require assistance.

Money and Time Management

Allow extra time, especially for novel tasks/situations.

Assist to establish and maintain a daily routine. Use of a large calendar in plain sight is recommended, although use may require ongoing assistance.

Involve in familiar household tasks with verbal instructions (e.g. sweeping, washing dishes, folding laundry, and cleaning tables).

Assist to incorporate social and leisure activities into a daily routine.

Money management may require total or close supervision.

Learning Strategies

Provide cues to assist with staying focused on the present task.

Verbal skills may be better than novel task performance abilities and may be deceiving.

Teach tasks using demonstration, verbal instruction, slow pace and repetition (2-3 steps at a time).

Learning within one environment does not guarantee the ability to generalize to another. Provide assistance within new situations or environments.

Avoid giving directions over the phone.

Allow the client to experience cause & effect as appropriate.

Remember that only the immediate consequences of actions may be recognized. Learning is often through repeated trial and error.

The individual may have difficulty with impulsivity and require assistance to recognize when this becomes problematic–socially and/or functionally.

Assistance is required for realistic planning, goal setting and follow through. ***Refer to enclosed “sensory diet” guide for additional recommendations.

Reference



42

OCCUPATIONAL THERAPY LEVELS 5.0-5.2 CAREGIVER GUIDE

Allen Cognitive Level Screen (ACLS):

Date/Time screened: Screened by:

The Allen Cognitive Level Screen (ACLS) is a standardized assessment of current cognitive functioning. During illness, stress, or medication stabilization cognitive performance may be affected and can interfere with an individual’s daily functioning. The Occupational Therapy recommendations listed below are suggestions for the client and/or those providing assistance, and are meant to facilitate the best ability to function within the least restrictive environment.

To live alone in the community, weekly supervision is recommended in a safe environment with a well-established routine and safety plan(s).

Transportation

Assistance may be required to determine safe and functional transportation options, and to assist with the set up and/or availability.

Additional recommendations: .

Medication

Assistance is often required for recognizing the need for the ongoing medication

compliance and for understanding medical concepts.

Supervision for medication management and monitoring of effects is recommended.

Assistance is recommended to create and consistently utilize a medication schedule.

Assistance is required for recognizing the importance of taking medications as directed.

The use of a weekly pillbox or bubble packaging may be helpful.

Additional recommendations: .

Nutrition and Cooking

Balanced meal planning and shopping may require assistance. Assistance for ongoing recognition of the benefits of a healthy diet is recommended.

Use of appliances with an automatic shut-off may be helpful.

Money Management

Assistance may be required for banking, paying bills/check writing, weekly/monthly budgeting, planning for unforeseen expenses, and the future.

43

Overspending/credit problems or under spending are often problematic and a significant source of stress.

Time Management The following are often helpful tools for time management although assistance may be

required to develop and utilize appropriately:

Checklists Use of daily/weekly planners

Use of a calendar

Dry erase boards

Structure is recommended to support and maintain recovery. The following options have been explored:

Partial hospitalization program/out-patient program: Day Program:

Volunteer work/Employment:

Educational Program:

Other:

Assistance may be required to establish a balance of work, rest, leisure, and exercise opportunities into the daily/weekly routine, and for follow through - as appropriate.

***Refer to the “sensory diet” guide for techniques determined useful this hospitalization, and assist with incorporating the techniques into the routine and/or environment, as appropriate.

Learning Strategies

Provide cues to assist with staying focused on the present task. Verbal skills may better than novel task performance abilities, and may be deceiving. May work at a slow pace.

Learning within one environment does not guarantee the ability to generalize to another. Therefore, assistance is recommended within new situations or environments.

Avoid giving directions over the phone.

Remember that only the immediate consequences of actions may be recognized.

Learning is often through trial and error.

The individual may have difficulty with impulsivity and require assistance to recognize when this becomes problematic – socially and/or functionally.

Assistance is required for realistic planning, goal setting, and follow through.

Reference

Allen, C.K., (1999). Structures of Cognitive Performance Modes. Ormond, Florida: Allen

Conferences. Compiled by: Tina Champagne M.Ed., OTR/L, Allen Authorized Advisor,

International ~ 10/2001

44

Allen Cognitive Level 2 Sensory Diet Guide

Listed below are types of stimulation generally appropriate for individuals at this level of cognitive

functioning. Things checked off have been utilized during this admission and have had positive

results. Caregivers will need to initiate, facilitate, set up and help to incorporate the following

suggestions into the individual’s daily routine and modify as appropriate. See the corresponding

caregiver guide and discharge summary for additional recommendations.

General guidelines:

Approach from the front, from within one’s visual field and with a slow-pace

The environment: consider whether it may be over- or under-stimulating and modify accordingly

Gravitational insecurity: may strike out, grab, yell or appear stubborn if feeling insecure when touched or when being moved

Consider the influence of sensory impairments, sensitivities, specific tendencies or sensory deprivation

Recognize age, cultural considerations and what is meaningful to the person

Be aware of any allergies, seizure history and diagnostic considerations before using sensory-based techniques.

Combining of the different types of stimulation below may increase the intensity of the stimulation provided

Proprioceptive Cues

Generally attentive to: Positioning/movement, own body, furniture, own clothing, & others when in their visual field/awareness. Proprioceptive cues may help the person feel safe and secure when being moved or during transfers.

Sensory Stimulation & Activities

o Weighted blanket/weighted lap pad/weighted vest/wrist weights/ankle weights o Blanket wraps o Therapeutic use of touch/massage/hand hugs o Objects to grasp/hold (towel) o Drinking through straws/sucking thick liquids through straws o Wilbarger Protocol/joint compression o Walking with assistance o PROM/AAROM/reaching activities o Therapeutic listening: o Music/singing/musical instruments/sound machine o Aromas/scented lotions: o Different tastes o Stuffed animals/dolls/pillows – with favorite materials/lightly weighted o Lighting/lighting equipment (bubble lamp/projector/mobiles) within visual field o Bean bag chair/glider rocker o Various types of chair pads/textured cushions/vibrating pad or recliner o Other: __________________________________________________

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Allen Cognitive Level 3 Sensory Diet Guide

Listed below are types of stimulation generally appropriate for individuals at this level of

cognitive functioning. Things checked off have been utilized during this admission and have had

positive results. Caregivers will need to initiate, facilitate, set up and help to incorporate the

following suggestions into the individual’s daily routine and modify as appropriate. See the

corresponding caregiver guide and discharge summary for additional recommendations.

General guidelines:

Approach from the front, from within one’s visual field and with a slow-pace

The environment: consider whether it may be over- or under-stimulating and modify accordingly

Gravitational insecurity: may strike out, grab, yell or appear stubborn if feeling insecure when touched or when being moved

Use distraction techniques to interrupt perseverative behaviors

Consider the influence of sensory impairments, sensitivities, specific tendencies or sensory deprivation

Recognize age, cultural considerations and what is meaningful to the person

Be aware of any allergies, seizure history and diagnostic considerations before using sensory-based techniques.

Combining of the different types of stimulation below may increase the intensity of the stimulation provided

Tactile Cues

Generally attentive to: Material objects or people within arm’s reach, exterior surfaces, exits,

familiar faces, music, and movement. Activities involving repetitive actions are often enjoyed.

Sensory Stimulation

o Rocking chair o Glider rocker o Vibrating pad/vibrating recliner o Bean bag chair o Bubble lamps/lighting equipment:

o Therapeutic listening:

o Sound machine:

o Music/sing-a-longs/musical instruments o Sucking thick liquids through straws o Different tastes/textures/temperatures of foods as appropriate (Ex:

sweet/sour, chewy/crunchy, cold/warm) o Various types of chair pads/textured cushions o Stuffed animals/pillows-with favorite materials/weighted o Wilbarger Protocol

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o Joint compression o Therapeutic use of touch:

o Blanket wraps/warm blankets o Weighted blanket/weighted lap pad o Weighted vest/wrist weights/ankle weights o Weighted utensils/weighted pens o Koosh balls/larger-sized assorted manipulatives o Aromatherapy:

o Scented lotions:

o Use of lighting/projector:

o Other:

Activities

o Feeding self as appropriate o Walking, with assistance as needed o AROM/AAROM/PROM

o Seated stretching/reaching activities with assistance as needed o Wiping surfaces/tables o Folding towels/clothes o Manipulating objects: larger-sized items of interest/of varying textures o Putting objects into containers/out of one to another o Polishing items o Balloon volleyball o Blowing, catching or swatting at bubbles o Tossing games: particularly those that do not require bilateral coordination o Oil/water toys o Singing/humming o Use of instruments o Clapping o Use of building blocks o Large-sized puzzles o Items from past roles to manipulate or use o Basic craft activities with assistance as needed o Painting with assistance as needed o Sanding wooden objects o Writing o Coloring o Sewing cards/basic sewing-running stitch

o Others:

Additional Comments:

47

Allen Cognitive Level 4

Sensory Diet Guide

Listed below are types of stimulation generally appropriate for individuals at this level of cognitive functioning. Things checked off have been utilized during this admission and have had positive results. Caregivers will need to initiate, facilitate, set up and help to incorporate the following suggestions into the individual’s daily routine and modify as appropriate. See the corresponding caregiver guide and discharge summary for additional recommendations.

General guidelines:

o The environment: consider whether it may be over- or under-stimulating and modify accordingly

o Consider the influence of sensory impairments, sensitivities, specific tendencies or sensory deprivation

o Recognize age, cultural considerations and what is meaningful to the person o Be aware of any allergies, seizure history and diagnostic considerations before using

sensory-based techniques. o Combining of the different types of stimulation below may increase the intensity of the

stimulation provided

Visual Cues

Generally attentive to: People, places, and things within their visual field, two-three step directions, simple/concrete goals and activities of interest.

Sensory Stimulation

o Rocking chair o Glider rocker o Bean bag chair o Swinging o Bubble lamps/lighting: o Light box protocol: o Therapeutic listening: o Sound machine: o Music/singing/humming/whistling o Sucking thick liquids through straws o Different tastes/textures/temperatures of foods as appropriate (Ex:

sweet/sour, chewy/crunchy, cold/hot) o Aromas/Scented lotions o Various types of chair pads/textured cushions

o Stuffed animals/pillows - with favorite materials o Bean bag tapping/self-massage o Wilbarger Protocol o Joint compression o Blanket wraps o Weighted blankets/weighted lap pad/ weighted vest o Wrist weights/ankle weights

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o Ice: _______________________ o Hot/cold pack: ___________________________ o Hot/cold bath or shower: ___________________________ o Vibrating cushion/vibration: o Other:

Activities

o Activities of daily living o Isometric exercises o Bean bag tapping o Stretching o Walks o Fidgets/stress balls o Bingo o Basic card games o Target games o Tossing games o Clay/Dough kneading o Cooking/baking with assistance if needed o Crafts o Painting o Coloring o Drawing o Sewing/knitting/crocheting o Crosswords/word finds o Puzzles o Videos o Gardening o Dancing o Basic cleaning tasks o Karaoke/use of basic hand held instruments o Other: ________________________________________ o Additional Comments: _____________________________________________________

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Create Your Own Personalized Sensory Diet

Check off the things that are helpful to you!

Sensory Stimulation

o Rocking chair o Glider rocker o Bean bag chair o Hammocks o Swinging o Different types of chair pads/textured cushions o Lighting:

o Bubble lamps o Fish tank o Rock waterfall o Therapeutic listening:

o Sound machine:

o Music o Singing/humming/whistling o Sucking thick liquids through straws o Ice o Biting into a lemon o Different tastes/textures/temperatures of foods, as appropriate (Ex:

sweet/sour, chewy/crunchy, cold/warm) o Stuffed animals/pillows-with favorite materials o Rubber-band snapping on wrist o Bean bag tapping/self-massage

o Brushing/joint compression:

o Blanket wraps o Weighted blankets/ weighted vest/weighted lap pad o Wrist/ankle weights o A reasonably weighted back pack o Aromas/scented lotions/candles o “Safety kit”: helpful items kept in a box/bag for sensory modulation. o Other:

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Activities

o Mindfulness activities with sensory cues o Isometric exercises/stretching o Use of exercise equipment or videos o Aerobics o Yoga/Tai chi/Pilates o Deep breathing techniques/tapes o Progressive relaxation tapes o Hot bath/shower o Playing sports/watching sports o Biking o Walks o Running o Roller-blading o Hiking o Use of therapy balls o Crafts/models o Sewing/knitting/crocheting o Making jewelry/beadwork o Artwork o Collage/mandalas o Pottery/ceramics o Playing an instrument o Karaoke o Cleaning o Cooking/baking o Gardening/flower arranging o Yard work o Driving o Use of Fidgets/stress balls o Use of relaxation CDs

o Calling a friend/family member

o Other: ___________________

Common Sensory Considerations

o Be cautious of any allergies/adverse reactions o Environmental considerations: recognize things that are grounding to you and things that are

triggers o Sensory impairments – (examples: hearing or visual) o Any sensory sensitivities, tendencies and preferences o Combinations of the suggestions listed above will increase the intensity of the stimulation

provided

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References

Allen, C. K., Earhart, C.A., & Blue, T. (1992). Occupational therapy treatment goals for the physically and cognitively

disabled.

Allen, C.K., Earhart, C.A., & Blue, T. (1995). Understanding Cognitive Performance Modes

Allen, Claudia K (1991). Cognitive Disability and Reimbursement for Rehabilitation and Psychiatry, Journal of

Insurance Medicine 23(4),

Allen, C.K., Austin, S. L., David, S. K., Earhart, C. A., McCraith, D. B., & Riska-Williams, L. (2007). Manual for the Allen

Cognitive Level Screen -5

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