Level 3 Review
The topic for this month is focused on successfully serving the person who is functioning in the Middle Stage of dementia.
STOP: Please complete the following activity
What Allen information have you committed to your memory? We have found through practical experience, that the more information that you can commit to memory, the better you will be able to observe the "abilities" the person demonstrates in everyday activity.
Try answering the following questions without looking at a resource. Whatever questions you miss, try to make a commitment to memorize and you will find yourself far more efficient in using the Allen theory.
- What is the name of Allen Level 3?
- What developmental age is this correlated to in the Theory of Retrogenesis?
- What are the names of the modes in Allen Level 3?
We correlate Middle Stage dementia to Allen Level 3 (Adapted FAST scale score 6). Allen Level 3 is called Manual Actions, as the primary functional ability of this stage is to use the hands to hold and manipulate objects and tools. The person in Allen Level 3 (based on our knowledge of the Theory of Retrogenesis) has similar functional and behavioral characteristics to that of a two- to four-year-old.
Allen Level 3 modes:
3.0 Grasp objects (purposeful grasp and release)
3.2 Distinguishes between objects (demonstrates proper grasp pattern on objects)
3.4 Sustains actions on objects (may look perseverative)
3.6 Notes the effects of actions on objects (cause and effect; able to sort; uses mirrors during ADLs)
3.8 Uses all objects and senses completion of an activity (may layer clothing; may cover all space or use all objects to help determine completion)
Please note that our team believes there are rather significant differences in the function and behavior of someone performing in Low Allen Level 3 (3.0, 3.2, 3.4) compared to High Allen Level 3 (3.6, 3.8). Some of the specific areas in which variation of abilities will be seen within level 3 are (a) the ability to process a verbal cue without the need for the addition of a visual or tactile cue (this refers to verbal comprehension skills), (b) the ability to chunk steps of a highly familiar, simple activity together from memory (this refers to sequencing ability), (c) the level of attention, and (d) the person’s speed of processing, to just name a few examples.
Throughout all of level 3 there seems to be a greater recognition and identification of the person’s disabilities as opposed to remaining abilities. That is because it takes some real skill, creativity, and heart to discover what really lies within.
Patients in Need
Through my work as a consultant in long-term care communities, I continue to see approximately 40 to 50% of the long-term residents functioning in the Middle Stages of dementia. Research does indicate the largest population of people with Alzheimer’s and related dementias to be currently functioning in early stage, but we certainly see many individuals who are in the middle stage in all living environments. And, the middle stage is the stage in which the person typically presents with many reasons for an occupational, physical, or speech therapist to become involved providing skilled service.
Reasons for Referral
Some common "reasons for referral" for a person in Middle Stage dementia:
- ADL decline
- Behavior disturbances that interfere with function or safety
- Falls or change in mobility status
- Weight loss or dehydration
- General safety impairments
- Communication disorders
- Excess disability
As we have stated many times, the middle stage is the stage in which the person is usually suffering from "excess disability." Simply stated, the person has many remaining abilities that the caregiver is unable to identify or use during daily activities, so the person performs lower than his/her capability level. Decreasing "excess disability" by (a) enabling the person to engage in an ADL at a higher level, (b) enabling the person to walk instead of being wheeled, and (c) enabling the person to communicate needs instead of being considered "unable" are all examples of skilled service needs.
One of the greatest areas of skill that the therapist must possess to evaluate and treat these individuals successfully is the ability to facilitate the remaining abilities. Concurrently, the therapist must possess keen observation skills. Often the ability is there, right before your eyes, but you may not be able to facilitate or identify it.
Some keys to facilitating remaining abilities in a person functioning in Middle Stage dementia:
- Keep environmental distractions to a minimum.
- Work hard to successfully gain the person’s attention. Don’t bother giving any directions until you have gained their attention.
- Provide the appropriate cues to facilitate a response including verbal cues, verbal with visual cues, or verbal with tactile cues.
- Use the appropriate communication style such as avoiding pronouns, speaking slowly, and speaking in short sentences.
- Modify the environment to promote interest and to tap into long-term memory. For example, present items that are familiar to the person and add colorful, highly striking, safe props as much as possible.
Examples of Allen Level 3 Abilities in Functional Activities
The following is a list of practical examples of abilities that you might observe in daily activities at each level 3 mode. Our team has used cognitive activity analysis, based on the Allen theory, to provide the examples below.
Activity: Stir Batter to Make a Cake (if a familiar activity)
- Briefly holds wooden spoon when placed in hand, drops spoon.
- Grasps spoon when placed in hand, may make a few "stirring movements" with spoon, but does not maintain attention to stir batter.
- Grasps spoon when placed in hand, stirs batter (in visual space) when provided with simple verbal and tactile cues, and continues stirring for a short period of time.
- When provided with simple verbal instructions and demonstration, picks up spoon (in visual space), stirs batter, and may note that lumps are smaller with stirring.
- Picks up spoon and begins stirring when directed to do so. May stir vigorously and may need cueing to stop stirring.
Activity: Scoop Dry Dog Food to Feed Dog (if a familiar activity)
- Briefly holds scoop when placed in hand, drops scoop.
- Grasps scoop when placed in hand, may make a few "scooping movements" with the scoop, but does not maintain attention to scoop dog food.
3.4 Grasps scoop when placed in hand, scoops dog food (in visual space) when provided with simple verbal and tactile cues, continues "scooping movement" for a short period of time.
3.6 When provided with simple verbal instructions and demonstration, picks up scoop (in visual space), scoops dog food, and places dog food in dog dish (consistent cues provided).
- Picks up scoop and begins scooping dog food when directed to do so. Places dog food in dog bowl (all in visual space). May continue this process without recognition of amount needed in bowl (overfeeding dog).
Activity: Apply Hairspray (if a familiar activity)
- Briefly holds hairspray when placed in hand, drops spray.
- Grasps hairspray when placed in hand, placing forefinger on top on spray (may look clumsy), may appear to press down on spray but unsuccessful.
3.4 Grasps hairspray when placed in hand, maintains forefinger on top of spray, attempting to push down on spray, attempts for a short period of time.
3.6 When provided with simple verbal instructions and demonstrations, picks up can of hairspray (in visual space), points hairspray at hair, and begins spraying (may spray too long in one spot). Looks in mirror while spraying.
- Picks up hairspray and begins spraying hair when directed to do so. May spray hair excessively, continuing to spray until there is nothing left in the can.
Activity: Use a TV Remote Control (if a familiar activity)
- Briefly holds remote when placed in hand, drops remote.
- Grasps remote when placed in hand, places thumb or forefinger on a button (may look clumsy), may be unsuccessful when attempting to press down on button.
3.4 Grasps remote when placed in hand, maintains thumb or forefinger on buttons, presses down on buttons for a short period of time.
- When provided with simple verbal instructions and demonstration, picks up remote (in visual space), points remote at TV (also in visual space, very familiar location), presses on buttons, notes if there is a change on the TV from pressing.
3.8 Picks up remote and attempts to turn on TV or change channel when directed to do so. If unsuccessful, continues to press all the buttons, may continue to press buttons without choosing a program to watch.
Activity: Use a Washcloth
3.0 Gross grasp and release of washcloth when placed in close proximity or directly in hand (very brief grasp, then may drop the cloth).
3.2 Appropriate grasp pattern on washcloth. May make minimal movements (actions) for proper use for short duration of time with verbal and visual cues or verbal and tactile cues.
3.4 Appropriate grasp pattern on washcloth. May make movements (actions) for proper use, although usually in same area (looks perseverative). Can be sequenced to next area for washing (e.g., hand to arm). May stop after short duration or continue too long with action in same area. Will need verbal with visual cues or verbal with tactile cues.
3.6 Appropriate grasp pattern and use of washcloth. May begin movements and chain parts of the movements together (i.e., moves location of washcloth to another part of the body without cue). Looks at what they are doing (i.e., noting effects of actions). May only wash easy-to-see locations (arms, legs, front of chest, etc.). Will require verbal cues.
3.8 Appropriate grasp pattern and use of washcloth. May chain steps of activity together and wash different parts of body without cue. However, may wash same areas over again, forgetting areas have already been washed. May need to be cued to stop.
Activity: Sand a Piece of Wood (if a familiar activity)
3.0 Gross grasp and release of wood or sandpaper when placed in close proximity or in hand (very brief grasp, then may drop the item).
3.2 Appropriate grasp pattern on wood and sandpaper. May make minimal movements (actions) for proper use for short duration of time with verbal and visual cues or verbal and tactile cues.
3.4 Appropriate grasp pattern on wood and sandpaper. May make movements (actions) for proper use, although usually in same area (looks perseverative). Can be sequenced to next area for sanding. May stop after short duration or continue too long with action in same area. Will need verbal with visual cues or verbal with tactile cues.
3.6 Appropriate grasp pattern and use of wood and sandpaper. May begin movements and chain parts of the movements together (i.e., moves location of sandpaper to another part of the wood without cue). Looks at what they are doing (i.e., noting effects of actions). May only sand easy-to-see locations (i.e., not corners). Will need verbal cues.
3.8 Appropriate grasp pattern and use of wood and sandpaper. May chain steps of activity together and sand different parts of wood without cue. However, may sand same areas over again, forgetting areas have already been sanded. May need to be cued to stop.
Stop: Please Complete the Following Activity
Try your hand at cognitive activity analysis. This exercise will greatly help you in your transition to becoming a highly skilled dementia therapist.
- Please identify the abilities associated with the activity of "setting a table" for each Allen level 3 mode. Follow the format used in the examples listed previously. Assume the activity is familiar to the person.
- Please identify the abilities associated with the activity of "using a dowel rod with weights during an upper extremity exercise program with a therapist." You can assume this is an unfamiliar activity. How will the fact that it is unfamiliar effect the person’s performance and the needed support?
Also, please identify the specific ways that you will need to adjust your approach and the environment in order to identify and facilitate the person’s best ability to perform these activities.
As a therapist, you will see many Allen Level 3 patients in homecare, long-term care, hospitals, and geriatric psych units. Many of these individuals present with daily functional, behavioral, or safety issues that require the services of a skilled therapist. Prior to learning the Allen theory, I ignored these patients, believing that they were not capable of participating and benefiting from my occupational therapy services. I was wrong. But the therapist must possess the advanced skills to screen, evaluate, treat, and document in order to facilitate and demonstrate positive outcomes. The utilization of the Allen assessment and treatment techniques will enable you to competently serve this significant group of individuals.
Our team loves working with the person in Allen Level 3 because we are usually able to facilitate tremendous changes in function, behaviors, safety, and quality of life. These persons are just waiting for a caring dementia therapist to come along who can see what they are capable of achieving. Imagine life without dignity. Imagine life without purpose. Imagine life without accomplishment. Imagine life without love. Each person in Middle Stage dementia is fully capable of achieving a sense of dignity, purpose, a feeling of accomplishment, and love. But, they are often prisoners of their shell of disability, waiting for you to unlock their vitality.
Allen, C.K., Earhart, C.A., and Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: American Occupational Therapy Association.
Reisberg B, Franssen EH, Souren LEM, Auer SR, Akram I, Kenowsky S. Evidence and mechanisms of retrogenesis in Alzheimer’s and other dementias: management and treatment import. Am J Alzheimer’s Dis. 2002;17(4):202-212.