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Introduction  

Allen Cognitive Disability Model screen measures limitations that come secondary to deficits to decline in mental functioning. Through evaluation of a client, a score is given based on their cognitive level. There are 6 levels of cognitive function. For our case study, our client has an ACL of 4 requiring 42% cognitive assistance and 8% physical assistance to complete activities of daily living. While a client with a cognitive level of 4 can be independent in self-care, they still require 24-hour supervision due to safety and awareness and have an attention span of 1 hour (Allen, 1995). A client with the score of 4 has the ability to pay attention to activity to be completed and aware of sequencing for activities. Client can notice objects within reach and recognize familiar possessions used in self-care. Client does not set up or cleans up before and after an activity and can recognize errors but has trouble correcting them (Allen, 1995).

A therapist working with a level 4 client should provide visual demonstration and should limit instruction during intervention to one step at a time. When working with objects, make them clearly visible and provide the client with visual comparisons on how to complete the activity (Brown, 2011).

Theory

When looking at individuals who were born with cognitive impairments or acquired cognitive impairments later on in life, it is important to look at more than just the person deficits. According to the Person, Environment, Occupation (PEO) model an individual’s occupational performance is influenced by the interaction between these three. The more each of the three are enhanced individually, the better they will work together to achieve an improved occupational performance (Law et al., 1996).  By using the Allen Cognitive Disability Model we are taking a closer look at the environment component of the PEO model and working on enhancing it. This model seeks to create a situation, or adapt an environment, in which people with cognitive impairment can be successful. After determining the level of cognitive function, using the ACLS, the model informs practitioners on the types of interventions that will help clients succeed with the ultimate goal of forming an environment in which the client will be least restricted and be at optimal safety (Brown, 2011).

Evidence

Cognitive Adaptation Training (CAT) is a compensatory approach that can be used as an in-home intervention to target real world problems in the client’s natural setting. CAT interventions are strongly individualized, use environmental supports, and tackle specific problems in their daily living activities (Stiekema et al., 2015). Effects of CAT include improvements in everyday functioning, quality of life, and medication adherence (Stiekema et al., 2015). A CAT intervention with a client suffering from poor executive functioning has been shown to benefit from large signs, more specific and more numerous stepwise instructions (Stiekema et al., 2015). Furthermore, CAT has been shown to be associated with fewer symptoms, fewer relapses, and better functioning (Brown, Stoffel, & Munoz, 2015). Given this information it seems clear that the benefit outweighs the harm for clients that qualify for this type of intervention.

Case Study

Samuel is a 28-year old veteran of the army national guard. He was recently receiving occupational therapy for behavioral problems secondary effects due to his TBI and was discharged. Samuel experienced the TBI on convoy in Afghanistan, when he encountered an improvised explosive device (IED). Recently, Samuel was involved in a motor vehicle accident and was transported to Baptist Hospital where he was treated and diagnosed for a second TBI and an open wound to the skull due to the automobile accident. He has now been discharged to home health. Samuel has been reporting difficulty remembering the sequence of steps to complete simple activities. Client also reported igniting a dryer fire because he keeps forgetting to clean the lint filter. His wife also reported recently becoming increasingly frustrated with Samuel because he has bleached her clothes for work and they have gone through 2 buckets of detergent in four days. She is worried that she might need more assistance with Samuel because she fears for his safety and needs help in the home. The Allen Cognitive Levels scale was used to assess and determines Samuels’s cognitive level where he scored a 4.0.

Intervention Plan

Problem Statement

Samuel is unable to safely wash and dry his laundry due to impaired cognitive functioning.

Long Term Goals

1. Samuel will be able to setup needed supplies to wash his clothes with caregiver supervision with 1 verbal cue for safety precautions in 6 weeks.
2. Samuel will be able to recognize safety hazards within his visual field for drying his clothes (removing lint) using a visual aid with supervision in 6 weeks.
3. Samuel will be able to correctly sequence the steps for drying his clothes with caregiver supervision for safety by using a simple and brief checklist in 6 weeks.

Short Term Goals

1. Samuel will be able to sort his clothes by color for washing with min assist by reporting like colors as “same” for each category in 3 weeks.
2. Samuel will be able to identify clothes are dirty and place them in the hamper using a brightly colored sign with 2 verbal cues from his caregiver in 3 weeks.

Intervention Format

Individual with caregiver present

Setting

The occupational therapist will meet with Samuel and his caregiver at their home 1x week for 40 minutes.

Supplies

Clothes, laundry supplies, hamper, material for a sign

Agenda

• Meet with Samuel and his caregiver / build rapport / concerns from caregiver (5 minutes)
• Discuss Samuel’s current cognitive functioning level (10 minutes)
  • Ability (precautions)
  • ACLS results
  • Address safety (supervision, hazardous objects)
  • Location and availability of supplies for laundry
  • Caregiver education (organizing laundry room, simplifying, declutter, keep items in same location)
• Educate caregiver and client on creating a large and bright sign for laundry (10 minutes)
  • Give them an example of a sign (bright, simply, short commands)
  • Have them create a sign for identifying dirty clothes and placing in hamper
• Client and caregiver practice using sign with clothing (10 minutes)
  • Provide feedback
  • Explain his current level of awareness
  • Give examples of cues
• Recap of session / answer questions (5 minutes)
  • Overview of tx session
  • Goal for next session

Documentation

S: “I don’t want my wife to worry about me helping out around the house”

O: Client and caregiver were present for the therapy session. Caregiver reports that her husband wants to help out with chores but feels he is unsafe and at risk when attempting chores. Caregiver reports that laundry is an area that he wants to help since she has a busy schedule. On more than one occasion she has caught him washing clean clothes and forgetting important safety steps while doing laundry. Client mentions he sometimes sees errors but doesn’t always correct it. The laundry room was inspected and evaluated. Caregiver was educated on how to create a simpler environment for her loved one so that he can help her in a safer manner. Education on decluttering, organizing, and simplification were given. Client and caregiver were educated on the benefit of having a large sign to accomplish the different steps involved with laundry. This included that the sign should be bright with simple commands. Client was eager to try using the sign that himself and the caregiver created. Client and caregiver were asked to use the sign to identify dirty clothes and place them in the hamper. Initially, the caregiver was providing verbal commands that were lengthy. Intervention was provided to correct. After 3 tries the client was able to follow the sign with his caregiver providing cues. Caregiver and client expressed gratitude for the guidance and a summary of the session was provided to ensure understanding.

A: Client and caregiver seem to have a relationship that can foster improvement in the client’s skills. Caregiver appears to be genuinely concerned and willing to address the deficits. Client is hopeful of improving which may help when setbacks occur. It appears that the client fails to correct his errors and is not currently capable of stopping an activity when safety concerns arise. Due to this, the client should be supervised at all times for safety and when around potentially hazardous objects. Caregiver and client were educated on his Allen Cognitive Level of 4.0. This indicates that his caregiver should be cognizant of his errors, use verbal cueing, and provide him with checklists for familiar activities. The caregiver was receptive to changing the format of the laundry room and it seemed beneficial to the client by reducing extraneous external stimuli. The sign for his laundry task proved to be effective for safe completion and beneficial to ease the caregiver’s burden.

P: Client needs to continue home health OT sessions 1x a week for 6 weeks to improve his IADL’s with environmental adaptations. Client and caregiver will benefit from further education on creating checklists to complete tasks within the home. Next tx session will focus on Samuels sorting his clothing by color to make appropriate and safe laundry loads.

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

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.

Stiekema, A. P., Quee, P. J., Dethmers, M., van den Heuvel, E. R., Redmeijer, J. E., Rietberg, K., & … van der Meer, L. (2015). Effectiveness and cost-effectiveness of cognitive adaptation training as a nursing intervention in long-term residential patients with severe mental illness: study protocol for a randomized controlled trial. Trials, 16(1), 49. doi:10.1186/s13063-015-0566-8