What Is the Allen Cognitive Level Screen?

Woman talking with senior about her memory
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The Allen Cognitive Level Screen (ACLS) is a test that evaluates the ability of someone to make decisions, function independently, safely perform basic skills, and learn new abilities. This assessment was developed by Claudia K. Allen, along with her colleagues. It was first published in 1985 and has been modified several times since then.

Rather than ask you to answer several questions verbally or through a pencil and paper test like many cognitive tests do, the ACLS test asks you to perform a series of sewing tasks using a flat leather string that has a light side and a darker side, a large blunt needle and a larger piece of rectangular-shaped leather with pre-made holes around the outside edges.

There are different versions of the ACLS available, including a disposable one for those with infection control concerns and a larger version for those with vision and coordination issues.

The ACLS is based on Allen's cognitive levels, which is a scale that include levels from zero to six that identify different cognitive abilities.

What Tasks Are Included in the ACLS?

The ACLS is unusual in that it uses the task of sewing stitches to evaluate cognition. The idea behind this is that each task requires a progressively more complicated level of understanding to complete.

Running Stitch: The first task of the ACLS is the running stitch. The test administrator demonstrates the stitch and then asks you to perform several of these stitches in a row.

Whipstitch: The second task of the ACLS is the whipstich. Again, the test administrator demonstrates the stitch, making sure that the directions are clear, and then asks the person to make several stitches in a row.

This task is more complicated because in addition to performing the more complicated stitch, you are also asked to always keep the light side of the leather string facing up and to make sure it's not twisted.

Error Correcting: Next, the test administrator takes the leather rectangle and sews the stitch incorrectly, making an error called the cross-in-the-back error and asks you to fix it.

The administrator then makes another stitching error called the twisted lace mistake and asks you to find the error and fix it.

Cordovan Stitch: The last stitch shown is the single cordovan stitch. Unlike the two prior stitches, the test administrator does not demonstrate how to make this stitch. Rather, she will simply show the completed stitch to you and then ask you to copy this stitch and make three of them.

How Is the ACLS Scored?

Scoring of the ACLS is based on the ability to complete the tasks given. The more difficult the stitch and task that is correctly completed, the higher the score.

Scores are broken down into numbers that correspond with specific levels of supervision and care that are likely to be needed to function in daily life. Scores range from a low of 3.0 to a high of 5.8.

A score of 5.8 means that in general, you are able to function quite well independently in your own home. You might benefit from education on topics such as the best way to position parts of your body to prevent pressure injuries from developing or suggestions on how to compensate when you're tired, but on a daily level, you really don't need any assistance.

A score of less than 5.8 indicates that you will likely need or benefit from some type of assistance in daily living tasks.

This could range from 24-hour nursing home care to periodic help in your home to assistance with only a few minor activities a week.

What's the Difference Between Allen's Cognitive Levels and the Allen Cognitive Level Screen?

Allen's Cognitive Levels: Allen's cognitive levels identify different levels of functioning on a 0 to 6 scale. Each level also lists the corresponding assistance needed to function as well as possible and to compensate for any deficits present at each level.

Allen Cognitive Level Screen: The Allen cognitive level screen is a specific set of tasks to assess where you fit on the different levels.

Scores of the ACLS range only from 3.0 to 5.8 since if you're at a cognitive level below a three, you would not be able to participate in this type of screening. The test scores stop at a 5.8 instead of a 6.0 because the test does not fully evaluate the ability to plan for the future.

Allen's Cognitive Levels

0 - Coma: A zero indicates that you are unable to respond and are comatose.

1 - Awareness: A score ranging from 1.0 to 1.8 indicates that cognition and awareness is extremely impaired. Total care 24 hours a day is necessary. 

2 - Large Body Movements: A score between 2.0 and 2.8 means that some mobility is present, but 24-hour care is needed to prevent wandering and to assist with all activities of daily living, such as bathing, eating, and hygiene.

3 - Manual Actions: Scores of between 3.0 and 3.8 reflect the need for supervision and assistance with activities of daily living. Providing cues, such as handing a toothbrush to you, will often trigger the result of brushing teeth.

4 - Familiar ActivityRoutines are very beneficial if you score between a 4.0 and 4.8. Safety issues and problem-solving are often a challenge; however, at the higher ranges in level 4, you may be able to live alone with a plan in place of what to do (such as calling a loved one) if an unexpected situation develops during the day.

5 - Learning New Activity: A score between 5.0 and 5.8 indicates that although there may be some mild cognitive impairment, you are often capable of learning new things and functioning quite well. If you are at the lower range of this level, you may benefit from weekly checks from a loved one or from other community support services. Those who score in the upper range are likely to function very independently and be able to perform a job well.

6 - Planning New Activity: A score of 6.0 is the highest score of Allen's cognitive levels and reflects intact cognition. Specifically, your executive functioning ability allows you to make decisions using good judgment and complex thought processes to plan ahead for the future.

How Is the Allen Cognitive Levels Screen Different from Other Cognitive Tests?

There are many assessments and screenings available to evaluate cognitive abilities. Many of these instruments screen for mild cognitive impairment and various types of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementia, and more.

Unlike many other cognitive tests, the ACLS is less of a diagnostic screening test. That means that while it can help identify cognitive problems such as dementia, it's more commonly used on a practical level to evaluate the abilities of someone to function in daily life. Rather than looking primarily at short and long term memory skills, judgment, and communication skills, it focuses more on executive functioning (which involves decision-making and judgment) and on how to provide assistance to maximize the remaining abilities.

For example, the MMSE (a frequently used cognitive test) evaluates several cognitive abilities and provides a score. However, it offers no suggestions as to how much assistance the person might need in daily life, nor does it try to apply the deficit in a cognitive area to practical living.

Sometimes, an individual may score at a certain level on a cognitive test and yet perform either better or worse in daily functioning because of how that cognition is used (or not used well) on a practical level.

The ACLS seeks to bridge that gap and also to provide specific suggestions on what types of support would maximize your cognitive abilities in daily tasks.

Additionally, most cognitive screens are administered by a social worker, psychologist, or physician. The ACLS is most commonly conducted, scored, and interpreted by the occupational therapy discipline, although others may be trained in it.

How Is This Test Used?

The ACLS is used as a practical assessment to determine cognitive and physical ability to evaluate safe living environments. The goal of the ACLS is the evaluation of functional cognition. Functional cognition refers to the mental abilities that help us perform daily tasks.

An occupational therapist may be asked to administer the ACLS to someone who is at an inpatient rehabilitation facility or a nursing home after a hospitalization for a fall and a hip fracture. This screen can help identify, on a practical level, how much assistance the person is likely to need because it not only provides a score, but the results include an interpretation of how that score will impact their ability to safely live at home and perform every day tasks. Recommendations may include the provision of meals and medications, assistance with finances and household chores, or 24-hour care.

The ACLS has also been used with adolescents and younger adults to evaluate functional cognition after brain injuries, in rehabilitation from drug addictions or overdoses and with mental illnesses such as schizophrenia.

How Accurate Is the ACLS?

Research demonstrates that results on the ACLS are quite accurate as compared to the participants' actual level of independence and their activities of daily living performance. It also has been validated by comparison to more typical cognitive tests, such as the MoCA and the MMSE.

What Are the Pros and Cons of the ACLS?

The ACLS is useful because it looks at how cognitive abilities affect daily life and it seeks to identify ways to compensate for lost skills.

However, it should not be used by itself to diagnose dementia. As with other screening tests, the ACLS can compliment other screening and medical tests if a dementia diagnosis is being considered.

The ACLS does require the use of both hands, as well as good visual and hearing abilities. Thus, if someone has impairments in any of these areas, the ACLS is not appropriate to use.

The ACLS can also be affected by test-retest learning. This means that if you have performed this test previously, you may be more likely to score higher on it. Also, if you have prior experience with these stitches, this could affect your performance.

A Word From Verywell

Concerns about memory and cognitive testing can be anxiety-producing. However, we hope you'll be encouraged after learning that the ACLS is focused on using and improving the skills that you have, not just on pointing out a possible problem. Using your strengths, in the area of cognition but also in all of life, is an important strategy to enjoying and improving your quality of life.

Sources:

Allen, CK., Cognitive disability and reimbursement for rehabilitation and psychiatry.Journal of Insurance Medicine, 23 (4), 1991. https://allencognitive.com/wp-content/uploads/Ed-Corner-Allen-Cognitive-Levels-and-Modes-of-PerformanceCombo.pdf

Clancy, C. and Chapman, R. Assisting Carers of People with Dementia through Dementia Education and Training for Carers. https://www.fightdementia.org.au/sites/default/files/Final-DETC.pdf

Earhart, C. The Allen Cognitive Group. A Brief History of the Cognitive Disabilities Model and Assessments. http://allencognitive.com/wp-content/uploads/Click-on-Brief-History-of-CD-model-2013-2FINAL.pdf

The Allen Cognitive Group. ACLS-5 and LACLS-5 Test: Psychometric Properties and Use of Scores for Evidence-Based Practice. 2016. http://allencognitive.com/wp-content/uploads/CopyrightReportfPsychometricsACLS-5_3-21-2016.pdf

The American Occupational Therapy Foundation. Research Priority: Functional Cognition. http://www.aotf.org/Portals/0/documents/About%20AOTF/Research%20Priorities/2016%20Functional%20Cognition%20Case%20Statement.pdf

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