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Introduction

Allen’s Cognitive Disability Model (ACL) measures the functional limitations of individuals with cognitive disabilities (Mayor, 1988). This model uses six hierarchical levels of cognitive functioning to determine a person’s cognitive abilities. Occupational therapists use this model to evaluate and treat clients with mental illness and neurological deficits. The goal is to determine their cognitive capacity and functional limitations to then reinforce and maintain what they have, and stimulate for further progression through the hierarchical levels. The ultimate goal is to increase occupational performance in these individuals.

Theory

According to Law et al., the person is dynamic and always interacting with the environment. When the environment is dynamic, behaviors change. The environment can have enabling or constraining effects on occupational performance. Thus, dysfunction occurs when there is poor fit between person, environment, and occupation. The environment is easier to change than the person. Occupational functioning increases when area of overlap expands between these three factors, there are better environmental supports, and a higher level of competence for occupational engagement. This model also suggests that occupational performance changes over the life span. It has a transactional, rather than an interactive approach towards the relation between the person and environment emphasizing the interdependence both.

Case Study

Rosa is a 52-year-old woman with type II diabetes who weighs 265 lbs (Cypress, 1999). She recently came out of a diabetic coma. She requires maximum cognitive assistance for ADL’s specifically grooming and toileting. In addition,  she is able to ambulate with minimal physical assistance. She is on watch 24/7 due to her increased risk of falling and her tendency to wander. She currently requires maximum assistance to initiate tasks (Cypress, 1999).

Evidence

There is substantial evidence that supports the use of Allen’s Cognitive Disability Model in mental health. For example, Raweh & Katz 1999 observed a significant change in cognitive ability in their mentally illed participants. The study found that their awareness about their abilities and deficits increased after receiving the ACL interventions.

Intervention Plan

Problem Statement

Client has difficulty with toileting secondary to poor sequencing skills

Long Term Goals

• Client will demonstrate toileting skills in correct sequence 4/4 times with 5 verbal cues in 4 weeks.
• Client will demonstrate wash hands after toileting 4/4 times with 5 verbal cues in 4 weeks.
• Client will demonstrate toileting using proper safety techniques 4/4 times with 5 verbal cues in 4 weeks.

Short Term Goals

• Client will demonstrate the don and doff of lower extremity garments for toileting following the proper sequence with 10 verbal cues in 5 sessions
• Client will demonstrate washing hands after toileting with 4 visual cues, in 5 sessions

Intervention format:

• Individual

Setting

• Home Health

Supplies

• Clipboard
• Generic checklist in black ink
• Red pen

Agenda

• 10-15 minutes: Establish rapport with client and caregiver, and develop occupational profile.
• 10-15 minutes: Have client complete ACLS (Allen Cognitive Level Screen).
• 10-15 minutes: Observe client perform occupational roles and document levels of assistance.
• 10-15 minutes: Develop plan for training and cognitive strategies.

Documentation

S: Client states, “I just woke up from being in a coma for 2 months, and I am scared. Oh shoot, I’m having a bowel movement. What do I do?”

O: Client participated in toileting activity and completed the following in 20 minutes: doffed pants, voided, performed perineal care, donned pants, tossed soiled tissue, flushed toilet, washed and dried hands to increase sequencing abilities during toileting. Tissue paper, pants, and soap are arranged in sequence along the bathroom sink. Client donned pants using 5 verbal and tactile cues to initiate task and pull up pants. Client required 3 verbal cues to initiate voiding. She performed perineal care with 2 verbal cues to initiate, and with the visual cue of placing a toilet paper roll in her line of vision. She donned pants with 2 verbal cues to initiate task and sustain attention. Next, the client flushed the toilet using 1 verbal and 1 tactile cue. Lastly, the client engaged in a 5 minute hand-washing activity. She required 5 verbal and tactile cues to initiate activity and open faucet, apply soap, wash hands, and close faucet to complete the toileting activity. The client was unable to identify or initiate the next step of the sequence during the toileting activity. Client required constant supervision during task due to wandering, which she attempted during three instances during the activity. Supervision was also provided to decrease risk of fall.

A: The client’s inability to initiate each step of the toileting task shows decreased cognitive ability to perform toileting and basic activities of daily living (ADL’s). Her inability to don or doff pants due to decreased attention and initiation shows decreased ability to engage in toileting, dressing, and other basic ADL’s. Furthermore, her inability to void without verbal cues shows decreased cognition to attend to tasks, which also show decreased ability to engage in BADL’s. Client’s ability to flush toilet with verbal and tactile cues shows decreased ability to initiate and sequence for BADL’s. The client’s inability to initiate and perform hand washing without verbal and tactile cues, shows decreased ability to engage and generalize skills to other ADL’s.

P: Client will initiate therapy 3 times a week for 1 hour per day to increase level in independence in tasks of daily living. At present, the client is dependent on caregiver for the majority of ADL’s. As such, caregiver will be provided training in proper transfer techniques and sequencing strategies. Client will be referred for a home- modification evaluation in order to improve functional ability within their residence.

24 hr assist

Wandering

Toileting

Grooming

Prevent falls

Indicates pref by pointing

Fine motor

Bed rails

References

Allen, Claudia K., Cognitive disability and reimbursement for rehabilitation and psychiatry. Journal of Insurance Medicine, 23 (4), 1991.

Dafna V. Raweh MSc, OTR & Noomi Katz PhD, OTR (2008) Treatment Effectiveness of Allen’s

Cognitive Disabilities Model with Adult Schizophrenic Outpatients, Occupational Therapy        in Mental Health, 14:4, 65-77, DOI: 10.1300/J004v14n04_04

Feil DG, Zhu CW, Sultzer DI. The relationship between cognitive impairment and diabetes   self-management in a population-based community sample of older adults with type 2 diabetes. J Behav Med 2012;35:190–199

Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. 1996. The Person- Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 63(1):9-23

Primozic S, Tavcar R, Aubelj M, Dernovsek M, Oblak M. Specific cognitive abilities are associated with diabetes self-management behavior among patients with type 2 diabetes.   Diabetes Res Clin Pract 2012;95:48–54