Many times the administration and scoring of higher level patients can be a challenge. For one, these are individuals who are typically independent in routine ADLs, such as dressing, bathing, toileting, etc. Secondly, despite having a mild cognitive impairment or demonstrating the early stage symptoms of dementia, these individuals still retain premorbid communication abilities. These abilities may be used to "cover" for their disability and fool even the skilled clinician into believing that higher level abilities exist.
This month we will discuss the administration, scoring, and interpretation of using the Allen Battery tools, specifically the Large Allen Cognitive Level Screen, the Routine Task Inventory, and clinical interview with these individuals.
A clinical interview is a good place to start in order to determine the person's own beliefs in their areas of strengths and abilities, and to assess if the person has insight into any disabilities which may exist. (Remember even at Allen Cognitive Level High 4 and Low 5 a person's judgment and insight may be impaired). An initial interview also assists with developing rapport with the individuals and with their families. This is extremely important, since the information you may need to provide in your recommendations may not always be the outcome the person (or the family) wants to hear.
If a family member is available, then I will often ask if they or someone else is providing assistance in any areas of ADL or IADLs. As my colleague Chris Ebell often states, if a family member has taken over the finances of the individual and there isn't a physical disability reason for it to be happening, then it may signal a red flag for you as a clinician, that a potential cognitive deficit may be impacting the activity.
Many times the administration of the LACLS can be intimidating for the higher level individual, (as well as for the clinician). An individual functioning at Allen level 4.6 or higher will usually be able to perform the running and whip stitches, and be able to problem solve the mistakes made in the whip stitch. This means you will need to move on to the single cordovan stitch to determine the cognitive level and mode. Be sure you are comfortable and knowledgeable with performing the single cordovan stitch, and that you are demonstrating the stitch according to the wording provided in the test booklet. This is significant since the scoring guideline takes into consideration each specific step and how the individual responds and performs the step.
The directions for the LACLS state to hand the individual the leather piece and ask them if they could replicate the single cordovan stitch and tell you what they are thinking as they perform the stitch. (I usually will not do this unless I really believe the person is high functioning). Even though the directions tell you to intervene if you see frustration or anxiety, I feel this can potentially detract from the therapeutic rapport and trust you have established with the individual.
Remember why you are using this tool. You are trying to determine what the individual's ability is to learn new, unfamiliar information (working memory). This is why the stitch is so complex.
Scoring for the single cordovan is based upon what you observe the individual do after the first demonstration, and then what you observe (if needed), after the second demonstration. This is why the sequence of the single cordovan stitch is so critical. You are observing how many of the steps the individual remembers from your demonstration. (There are at least seven different steps in order to complete the single cordovan stitch correctly). If you look at the scoring criteria in the revised (2003) test manual, you can see that as the individual remembers more of the lacing sequence, they are assigned a higher Allen cognitive score. (This is also based upon how many demonstrations you give the individual).
For example, the following are scoring criteria for 5.2 and 5.4.
5.2 Corrects errors in the direction taken to do the lacing and in tangled lacing; tightens lacing in sequence following a second demonstration; i.e., the loops are tightened in sequence, though the tension may be a little loose.
5.4 Following only one demonstration, the person corrects errors to the direction taken to do the lacing, in tangled lacing; tightens lacing in sequence without a second demonstration. The person is observed altering actions at least two times.
You must be sure to give the directions as accurately as possible, and make sure you are demonstrating each sequence of the stitch for the individual to follow; otherwise it may invalidate or skew your scoring.
Claudia Allen always says that the LACLS is only a screening tool. It gets you in the ballpark as far as assessing the individual's cognitive level. It should never be used alone without validating the score through functional performance. (Remember to look for a pattern of behavior.) The more extensive clear pattern of behavior that you are able to observe, the stronger your inferences and recommendations become.
The other Allen Battery tool I use to validate the LACLS score is the IADL areas of the Routine Task Inventory. (Found in Allen's Occupational Therapy Treatment Goals For the Physically and Cognitively Disabled). This is an invaluable tool since it can serve to validate the LACLS score and allow the clinician to "see" the individual's working memory capacity. There are several IADL areas to choose from which makes this tool practical in a variety of settings.
In order to administer and score this tool, one can ask specific IADL questions during the clinical interview, and/or interview caregivers about the individual's competency in the various areas; however, many times this information can be skewed by the informant. Our suggestion is to use your clinical observations, versus caregiver report in order to observe and score the individual.
The activity you select should be assessing the individual's working memory. (For example, if you choose doing laundry, make sure the washer is not familiar to the person. If you choose taking medications, make sure the medication routine is a recent change). Otherwise, you may be observing a procedural memory activity and the individual may appear higher functioning. As you observe the individual, remember to use your clinical reasoning skills to give the least amount of cues necessary in order for the person to perform the activity. This will give you a more accurate score of the Allen level and mode. Based upon what you observe, use the scoring guideline (analyzed by Allen modes) for each activity. Again, you should be looking for a pattern of behavior in the IADL areas you have chosen.
Often for individuals functioning in High Allen Level 4 or Low Allen Level 5, you may see rigidity or decreased speed of performance, difficulty learning without demonstrated assistance (because they don't generalize learning), and trial-and-error problem solving. You may actually hear the individual "blame" the supplies or items when they run into difficulty. Make sure you know when to intervene and support the individual; otherwise they may become frustrated and refuse to go further in the activity. Hopefully, a clear pattern of behavior will emerge once you have administered your assessment tools.
Finally, what you need to do is take into consideration how the Allen Cognitive Level and mode you've determined impacts on the person's safety and function. What type of living environments are they in or expected to return to? What are the expectations and demands of the environment? Does the person's Allen cognitive mode support this type of environment? These are questions that place us in not only a unique, challenging situation, but at times a difficult one as well. Be as prepared as possible, becoming familiar and competent utilizing the Allen Battery tools we've discussed.
This is a brief overview of using a few of the Allen Battery tools for assessing higher level individuals. Hopefully this information helps guide you in your clinical practice area. Please use our communication forums to provide feedback on what Allen assessment tools have been helpful for you and share some of your success stories with us. We'd love to hear from you.
Caroline Copeland, OTR/L
Dementia Care Specialists, Inc.