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Introduction

Environmental modifications suggested by Allen’s Cognitive Levels (ACL), are used for individuals with a disease or disability that has resulted in a diminished cognitive level of functioning. Due to the decreased cognitive ability, Allen’s Cognitive Levels is used to aid  the professional in understanding the person’s level of cognitive functioning. With this information, the professional can aid the caregiver by providing them with the necessary tools to help the client function at the most optimal level. The six cognitive levels are titled with the prominent, observable, voluntary motor actions associated with the level (Allen, Earhart, & Blue, 1992). The levels are created as a hierarchy of increase in complex abilities, with the fewest and simplest available cognitive capacities and functional abilities described by cognitive level 1 and the most complex by cognitive level 6.

Theory

The Person Environment Occupation Model (PEO) model follows a client-centered approach that guides the therapist in understanding occupational performance issues from the perspective of the client and supports the participation of the client throughout the intervention planning process. The PEO model understands the interrelationship of the person, their environment, and their occupations as they all affect one another (Brown, Stoffel, & Munoz, (2011).

Evidence  

David and Riley (1990) researched the validity of Allen’s Cognitive Levels (ACL) and the results indicated that it was a valid measure of cognitive functioning. The sample included a randomized controlled trial of  71 patients who were admitted to a general hospital psychiatric unit during a 13 month period. During the first week of admission, the participants were given the ACL that involved three leather stitches that increase in complexity. The ACL stitching test measured the level of reasoning needed to successfully complete the stitching. The results indicated that the ACL test relates more to the measure of visual motor speed and concentration than the measure of abstract reasoning. “These findings are consistent with those of Mayer (1988) and Katz (1985) and support the theoretical assumption of the ACL as a measure of sensorimotor cognitive functioning.”

Case Study

Gloria came to the United States 3 years ago to live with her daughter after escaping the cartel. Gloria was the only one of the family in Venezuela to make it to the US embassy. However, during the escape, Gloria sustained a traumatic brain injury when she was hit with shrapnel after a car bomb exploded. Gloria’s daughter, Yolanda, has been taking care of her mother since her injury but is having increased trouble keeping track of her mother because she has started wandering at night. Yolanda has been referred to OT by her doctor to help decrease the caregiver burden as well as to help with environmental modifications in the home. Gloria is at a 2.4 level of functioning based on the ACL.

Intervention Plan

Problem Statement

Caregiver is having difficulty caring for client secondary to safety risks and limited knowledge of impairment.

Short Term Goals

1. Caregiver will demonstrate knowledge of clients limitations and how to apply effective management strategies in 4 weeks.
2. Caregiver will demonstrate knowledge of fall/safety precautions in 2 weeks.
3. Client/caregiver will demonstrate knowledge and use of adaptive equipment for ADL’s in 2 months.
4. Client will initiate simple ADL tasks with 2 verbal cues with accuracy of 75% in 2 months.

Long Term Goals

1. Client will initiate and complete feeding tasks with set up and visual cues within 15 minutes in 4 months.
2. Client will advance to directed walking following provided visuals cues during treatment sessions in 6 months.

Intervention Format

Individual

Setting

Gloria will meet with the occupational therapist at her home for 30 minutes, 2x/week for 6 months.

Supplies

None

Agenda

• Meet Gloria and Yolanda to develop rapport to establish trust (2 mins)
• Education and training on specific tools/resources that can be used to help Gloria advance
• Yolanda will be given training in fall and safety precautions on how to properly use bed alarms (10 minutes)
• Train in use of safety and body mechanics (10 mins)
• Provide resources in respite care (8 minutes)

Documentation

S: Caregiver states that she feels overwhelmed taking care of her mother.

O: Client participated in a 30 minute session in which the caregiver discussed with the OT safety and fall precautions she will implement in the home. Gloria was taught these precautions along with her caregiver and demonstrated these techniques when prompted but was unable to repeat them on her own with no cues. Caregiver was also taught appropriate safety and body mechanics when bending and lifting to assist Gloria. Caregiver was also informed of additional resources for respite care.

A: Client’s ability to demonstrate the techniques taught indicated an ability to understand commands given; however, information was not retained for independence. The client’s inability to successfully replicate these techniques when prompted a second time demonstrates her need for a caregiver and further occupational therapy providing verbal or visual cues. Caregivers ability to verbalize and demonstrate proper bending and lifting techniques indicates an increased awareness of safety precautions for herself and Gloria.

P: Client will continue with OT sessions for 30 minutes, 2x/week for 6 weeks to focus on increasing ADL skills and use of adaptive equipment when needed.

References

Allen, C. K., Earhart, C. A., & Blue, T. (1992). Occupational therapy treatment goals for the physically and cognitively disabled. Bethesda, MD: American Occupational Therapy AssociationEd

Brown, C., Stoffel, V., & Munoz, J. P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia: F.A. Davis

Sandra K. David, William T. Riley; The Relationship of the Allen Cognitive Level Test to Cognitive Abilities and Psychopathology. Am J Occup Ther 1990;44(6):493-497. doi: 10.5014/ajot.44.6.493.

Allen Scale