Use of the Allen Cognitive Levels in Dementia Care

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This is the system of dementia staging that I like best, and that best coincides with my goals as a therapist.  I’ve spent a fair amount of time studying it, and have tried to incorporate it into my daily work.  It was first devised by Claudia Allen, an occupational therapist, and her colleagues in the late 1960s, in their work with patients who had mental disorders.  The theory has been well-known to occupational therapists for quite some time, but in the last several years has gotten the attention of other disciplines as well.  Others have continued the research started over 50 years ago, and the field of dementia care has been transformed as a result.

One major hallmark of the Allen Cognitive Levels is their focus on the person’s remaining abilities.  So, rather than focusing on what the person can no longer do, we instead look at what they are still able to accomplish, and how we can use those abilities to enhance their overall function.  The six levels were initially conceptualized as a sequence of sensorimotor abilities something akin to Jean Piaget’s developmental levels of cognition.  As Allen observed the function of her patients and other individuals, she theorized that this same sequence was present in those with mental illness, dementia, and fatigue in adults.

As research continued, a test was devised which involved the use of three increasingly complex sewing stitches on a piece of leather, known as the Allen Cognitive Levels Screening (ACLS).  This measure was standardized in 1978, and successive studies established inter-rater reliability, as well as correlations between the ACLS and other standardized psychological assessments.  The standardized directions for administration of the ACLS were first published in 1985, and have been revised several times since then.  In 1992, an alternate form of the test was made available for those with visual impairments and impaired hand function.

The original six cognitive levels have been expanded to include a number of different sub-levels, or modes, for each.  Additional assessments, as well as publications further delineating the levels and how to use them therapeutically, have been (and continue to be) produced by a number of individuals.  Currently, the cognitive disability model first proposed by Claudia Allen and her colleagues are being utilized by therapists working in the fields of mental health, forensic psychology, rehabilitative medicine, and geriatric care.  These professionals use the model to develop functional goals for individuals in a wide variety of settings.  But, regardless of where they are used or who uses them, they have proven invaluable in helping individuals maintain a sense of optimism (and realism) in their daily lives.

I was taught to look at the Allen Cognitive Disabilities Model as an explanation for how our brains process information.  One of the key concepts utilized is that of “functional cognition,” which takes in both what our brains pay attention to, and how it determines what it needs to in order to enable us to do certain tasks.  Through use of this model, we can learn more about how the person’s brain, through processing the signals it receives from the environment, controls his actions.  To a large extent, this is determined by what parts of the environment his brain pays attention to.  Hence, by analyzing how the person perceives the environment, and using that information, we can enhance his behavioral responses to that environment.

This is a very cursory explanation of how the model works, but I hope it’s enough to give the reader some understanding of the Allen Cognitive Levels, which I describe below.

There are six levels in the Allen model, as in another commonly-used system of dementia staging.  However, whereas that other system considers an individual functioning at level #1 to have “normal” cognitive functioning, the Allen model reverses that and ranks that same individual as being at level #6.  In addition to the basic six levels, the Allen model also describes 5 “modes,” or sub-levels, each one further describing the brain’s movement from one level to the next.

Allen Level 1:  Automatic Actions (The person at this level will require total care.)

1.0 — withdraws from stimuli (this is usually noxious, or unpleasant, stimuli)

1.2 — can respond to stimuli (this can be pleasurable stimuli)

1.4 — can locate stimuli (tries to determine where the stimuli is coming from)

1.6 — can move around in bed, usually without a specific purpose

1.8 — can raise body parts voluntarily

Level 2:  Postural Actions  (The person at this level will require maximum to extensive assistance, with constant cues.)

2.0 — can overcome gravity (can sit up without support)

2.2 — can stand up

2.4 — can walk, with support

2.6 — can walk to a particular location

2.8 — can use environmental objects for support

Level 3:  Manual Actions  (The person at this level will require moderate to limited assistance, with constant to intermittent cues.)

3.0 — can grasp and release objects with a purpose

3.2 — can determine how to correctly grasp different objects

3.4 — can sustain actions on objects

3.6 — can identify the effects his actions have on objects

3.8 — can use all objects and all senses to complete an activity (even if there may be errors in that completion)

Level 4:  Goal-Directed Activity (The person at this level will require minimum assistance, or close supervision.)

4.0 — can sequence self through the steps required to do simple, familiar activities (regardless of quality)

4.2 — can make distinctions between the component parts of an activity

4.4 — can complete a goal (with good quality)

4.6 — can scan the environment

4.8 — can memorize and learn steps of a new task

Level 5:  Independent Learning Activity (The person requires distant supervision for novel activities, or will be independent for familiar activities.)

5.0 — can understand the primary effects of his behavior, but not always the possible consequences, and can learn to improve that behavior

5.2 — can learn to improve the finer points of his behavior, and its consequences

5.4 — can learn independently

5.6 — can consider social norms, as well as the secondary effects of behaviors

5.8 — can take into account other people’s opinions on behaviors

Level 6:  Planned Activities (The person is independent in all things.)

To fully understand what these levels mean for the individual, and to determine how to use them to improve that person’s life, requires a more in-depth analysis, as well as a more detailed explanation of what each level means.  I hope to give more information about these things in future posts.  However, there are many other resources that will also provide information, and I will be pointing to them as well.

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