Definition/Introduction

Claudia K Allen and her colleagues formulated the Cognitive Disabilities Model (CDM), which stemmed from their observations of adult patients with persistent mental disorders such as schizophrenia and major depressive disorder. According to the CDM, most of these patients will experience diminishing abilities to perform activities of daily living (ADLs) and to function within their communities due to their mental illness. This cognitive impairment may be either temporary or permanent. Six cognitive levels, termed Allen Cognitive Levels, were derived from the CDM. The Allen Cognitive Level Screen (ACLS) was published in 1985, providing a tool to help quickly stratify the observed cognitive disabilities. The ACLS allowed assessment of patients’ cognitive functioning via observation of sensorimotor actions. The ACLS comprises a series of increasingly complex leather lacing stitches, and a numerical score ranging from 3.0 to 5.8 derives from how accurately the test subject can replicate the therapist’s stitches. A score of 5.8 predicts that the patient will be able to function well on his or her own, but a score of less than 5.8 indicates that the patient may benefit from additional assistance. This score allows the therapist to estimate the patient’s capability in learning, problem-solving and following directions. While modifications to the ACLS have been made since its original publication, it remains one of the most widely utilized tools for occupational therapists to help assess their patients. Because of the ACLS’s limited scoring range, patients at a cognitive level of less than 3 are unable to be test subjects for the screening tool. The test is also unable to accurately assess the patient’s ability to plan for the future, so its maximum score is capped at 5.8.[1][2][3][4][5]

Issues of Concern

There are six different levels in Allen’s model of cognitive levels. Each Allen Cognitive Level (ACL) provides a description of the patient’s level of occupational functioning and his/her ability to perform familiar activities, as well as to learn new ones. Each proceeding cognitive level in Allen’s model is cumulative. For example, a patient with the cognitive ability to perform at Level 3 would also is assumed to have the abilities required for Levels 1 and 2.

Level 1 describes automatic actions (e.g., swallowing, diverting attention towards stimuli). In other words, Level 1 describes the patient’s arousal to external cues. This cognitive level is largely instinctual behavior, and patients require total assistance with activities. A patient who is below cognitive level 1 would be in a coma.

Level 2 describes postural actions (e.g., gross movement in response to proprioceptive cues). The driver for the patient’s actions is primarily comfort or discomfort, remaining mostly unaware of the effects of their actions on their surroundings. Aimless pacing and/or wandering are observable in patients functioning at this cognitive level. Patients at Level 2 require maximum assistance.

Level 3 describes manual actions (e.g., grasping at and using objects). What distinguishes Level 3 from Level 2 is the increased ability to discriminate the external from the self. The patient’s global cognition remains impaired at this level, but long-term repetitive training can allow these patients to acquire new behaviors by better noting their effects on objects, sustaining their actions, and utilizing materials for ADLs. Despite their ability to sustain actions, patients at Level 3 still lack long-term concentration and may need frequent re-direction to complete tasks appropriately; moderate assistance is a recommendation for Level 3. 24-hour supervision should be in place for patients at Levels 1, 2, or 3.

Level 4 describes goal-directed actions (e.g., preparing a snack, following a route around a familiar neighborhood). At this level, the patients can recognize and understand the effect their actions have on their surroundings. Relying on visible cues, they can learn and carry out activities specific to particular goals. However, patients functioning at Level 4 still have trouble recognizing finer details and learning independently. Hence, they often lack the cognitive skills to identify and fix errors, and supervision in the form of minimum assistance is the recommendation for these patients.

Level 5 describes exploratory actions (e.g., problem-solving through trial-and-error). Patients at Level 5 of the ACLs can learn by emulation of actions shown to them. They are also able to apply what they learn to other activities and situations. Still, these patients have limited ability to organize, anticipate, and plan. This limitation can lead to poor judgment and higher impulsivity, especially in situations that require more deductive reasoning. External cues via supervision can help patients at this cognitive level plan. Patients at Level 5 should receive standby assistance.

Level 6 describes planned actions (e.g., anticipation and prevention of errors). There is no global cognitive impairment at this level, and the patient at this ACL is considered to be a normally functioning adult. It is important to note that because the ACLs describe cognitive levels, the patient may still have physical limitations. There is no supervision required at Level 6.[6][7][8][9]

Clinical Significance

The ACLS allows quick assessment of a person’s level of cognitive function via task-based assessment. The tool used for the screening is a leather plate with small circular holes all along the periphery. Using two needles and two strings, the therapist performs three various stitching tasks, with each task increasing in complexity in the level of lacing. The stitches performed are running stitch, whipstitch, and a cordovan stitch; error-correcting is also an assessed capability in the screening. A numerical score between 3.0 and 5.8 is assigned based on the test subject’s ability to replicate these stitches accurately.[4][10]

Nursing, Allied Health, and Interprofessional Team Interventions

Caring for patients with cognitive impairments can be a difficult task. First, the healthcare provider must distinguish between many processes that can lead to cognitive impairment (e.g., delirium, depression, schizophrenia, dementia, etc.).[11] In the hospital setting, nurses are usually the healthcare providers to first recognize changes from baseline in a patient’s cognition. Delirium, for example, can lead to a rapidly altered cognitive state in a patient. Properly trained nurses with experience and knowledge in delirium can help by quickly identifying this medical emergency and bringing it to the attention of a medical doctor. A timely diagnosis of delirium is crucial to providing effective healthcare, as it can significantly increase the length of hospital stay and mortality rates in patients. Another example of a common cause of cognitive impairment is depression. Nurses can help identify depression in patients through clinical assessment and observation. They also provide support for the patient by being at the bedside. While medical doctors can prescribe antidepressant medications to combat depression, therapists can provide tremendous help for the patient’s road to recovery either primarily or adjunctively. For patients who suffer from depression due to physical injuries and limitations, physical and occupational therapists play pivotal roles in the treatment plan. Dementia is the third example of a relatively common cause of cognitive impairment. Dementia ranges widely in the severity of cognitive impairment, depending on the state of the disease course.[12] Medical doctors can prescribe medications that can help sustain the patient’s cognitive function and slow the rate of decline. Nurses provide care for patients with dementia by being at the bedside in hospitals, nursing facilities, or even home. Therapists provide cognitive stimulation therapy, which has been shown through several independent studies to provide benefits in the cognition of patients with mild to moderate dementia.[13][14][15] [Level I]

Occupational therapy methods for screening functional cognition are of significant value for patient assessment. Knowledge of the level of function and understanding of this level assist occupational therapists in developing client-centered interventions. They identify the patients remaining abilities and strengths and identify safety issues and the appropriate level of supervision. The Allen Cognitive disabilities model is based on strengths, not disabilities, to promote the highest possible functional level. The model was developed while working with adult patients in mental health settings but is now applied in other areas.