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Introduction

The Allen Cognitive Level Screen Assessment or ACL scale measures functional capacity as a result of severe mental disease. The scores on the ACL scale range from 1-6, with a 1 being a comatose state capable of automatic actions and a 6 being capable of typical adult functions and planned actions (Brown, 2011). The focus of the cognitive disability model is to adapt the client’s environment so they may be successful at their current level of function. Occupational therapists are trained in making skilled observations of environments and physical barriers which allows them to create a match between the environment and client’s cognitive abilities (Allen, Earhart & Blue, 1995).

Theory

The Person-Environment-Occupation Model (PEO), is used by therapists to use in alliance with clients to elicit engagement in their meaningful occupations in the most natural of environments. (Strong, et al., 1998). It has been suggested that the environment is a critical influence on occupational performance and purpose. Environments that promote opportunities are more conducive to enhancing occupational performance. It has been suggested that the environment has a powerful impact on the individual compared to the length of treatment (Rebeiro, 2001). In many cases, a safe environment that also provides affirmation that the individual will be supported and valued, enables successful occupational performance. The PEO model assists in conceptualizing, analyzing and communicating possible occupational performance intervention (Strong, et al., 1998).

Evidence

A study in 2017 made up of a sample of 232 participants from an outpatient treatment center in Madrid, Spain were assessed utilizing the the Allen Cognitive Level Screen Assessment (ACLS-5), the Montreal Cognitive Assessment (MoCA), and the Prefrontal Symptom Inventory (PSI). More than half of the total sample of participants exhibited serious deficits in functional cognition, which in turn, may be related to disruptions in their daily performances. The study found that the accumulated scores of ACLS-5 showed significant correlations with the severity of addiction than with those obtained with the MoCA and the PSI scale. In addition, the data supports the use of the ACLS-5 when assessing the level of functional cognition in subjects facing addiction. This study demonstrates useful evidence to support and facilitate the development of cognitive rehabilitation programs from an occupational aspect. Occupational therapists working in this particular setting, benefit most from occupational-based instruments to assess the functioning of those with addictions (Rojo-Mota, et al., 2017). Although individuals with eating disorders are not considered to have an addiction problem, they share many qualities. In a sense, those with eating disorders are addicted to calorie restriction, excessive exercise, purging, etc. Therefore, the ACLS can be used with this population and one can assume similar results.

Case Study

Maurice is a 68 year old male who has battled anorexia nervosa for several years and was recently hospitalized for severe acute malnutrition and dehydration. Apart from other medical complications deriving from the recent medical complications, he has also been diagnosed with Reversible Cognitive Disorder, a result of the acute malnutrition. Maurice was assessed utilizing the Allen Cognitive Level Screen Assessment (ACL) and received a score of 4.2 in which he was determined to require 38% cognitive assistance, 8% physical assistance and 24 hour supervision. Currently his main concerns include fine motor issues, recognizing and correcting safety hazards. He spent 3 days in the hospital and is now being discharged with a plan to return home, a 1 bedroom single floor apartment in which he manages alone. He will receive occupational therapy in his home once a week to promote safe living decision making.

Intervention Plan

Problem Statement

Due to decreased cognitive abilities, client is unable to recognize and address safety hazards.

Long Term Goals

1. Client will prepare one stove top meal with supervision, using safety precautions, to engage in meal preparation within 4 weeks.
2. Client will safely navigate the kitchen environment with supervision to engage in meal preparation within 4 weeks.

Short Term Goals

1. Client will verbalize how to safely prepare one tv dinner meal within 3 minutes to engage in meal preparation within 2 weeks.
2. Caregiver will demonstrate proper verbal cues to participate in home safety activities within 2 treatment sessions.

3. Client will safely engage in grooming activities with 2 verbals cues within 1 week.

Intervention Format

Individual

Setting

Client will meet with therapist in home environment for 30 minutes once a week for 4 weeks.

Supplies

None

Agenda

• Therapist will explain to client the activity (5 minutes)
• Therapist will show 4 different pictures with hazardous events (5 minutes)
• Client will verbalize if the situation is safe or unsafe and will create a solution if unsafe (15 mins)
  • Client will verbalize why the situation is unsafe and explain how to resolve the problem.
  • Create one unsafe situation the client can encounter while making lunch
• Go over incorrect responses with client (5 minutes)

Documentation

S: “ I do not understand why I need someone in my house all day.”

O: The first two pictures the client was unable to identify any hazards, although given verbal cues. On the third picture, the client needed 4 verbal cues to identify the hazardous situation. On the fourth picture, he needed 3 verbal cues when creating safe solutions. Using visual and verbal cues, the client was able to think and describe to the therapist a hazardous situation that he can face while he is preparing lunch. Therapist went over incorrect answers with client. Client was responsive and understood mistakes made in the decision process.

A: Client’s ability to recognize hazardous situations within the pictures with verbals cues indicates that he has gained some insight on dangerous situations that he can face in his daily life. Client’s capacity to think about possible hazardous situations that can occur while preparing his lunch demonstrates his ability to solve daily situations safely.

P: Next session, client will continue working on improving safety awareness in order to live independently.

References

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

—Brown, C., Stoffel, V.C., & Munoz, J.P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia, PA: F. A. Davis Company. ISBN-10: 0-8036-1704-6

Rebeiro, K. L. (2001). Enabling occupation: The importance of an affirming environment. Canadian Journal of Occupational Therapy, 68(2), 80-89.

Rojo-Mota, G., Pedrero-Pérez, E. J., Huertas-Hoyas, E., Merritt, B., & MacKenzie, D. (2017). Allen Cognitive Level Screen for the classification of subjects treated for addiction. Scandinavian journal of occupational therapy, 24(4), 290-298.

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1998). Application of the person-environment-occupation model: A practical tool. Canadian Journal of Occupational Therapy, 66(3), 122.