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Creating an OT Toolbox of Assessments for Persons with Dementia

Creating an OT Toolbox of Assessments for Persons with Dementia
Sara Story, EdD, OTD, OTR/L, BCG, CAPS
September 10, 2019

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Course Overview

Today, I would like to discuss with you how we as OTs can create an OT toolbox of assessments for persons with dementia. I am a faculty member at Spalding University. I have a real passion for the older adult population, specifically helping those who have a diagnosis of dementia as well as caregivers that take care of individuals diagnosed with dementia. Today, my hope is to show you some of the assessments that I have utilized in practice and ones that are commonly utilized for assessing and screening individuals so that we can help them in their journey to be able to complete occupations and participate in meaningful tasks as long as possible. I would like to introduce the assessments to you, and then give you a brief overview of each individual one. I will then give a comparison of them on a conclusion slide.

Introduction of Assessments

  • Allen Cognitive Level Screen-5
  • Allen Diagnostic Module 2nd edition
  • Routine Task Inventory – Expanded
  • Global Deterioration Scale
  • Functional Assessment Staging
  • Cognitive Performance Test
  • Dynamic Lowenstein Occupational Therapy Cognitive Assessment- Geriatric
  • Mini-Mental State Examination 2nd edition
  • Montreal Cognitive Assessment
  • Saint Louis University Mental Status Exam
  • Short Blessed Test

Today I would like to present these assessments to you, giving you information to allow you to have them in an OT toolbox, regardless of the setting, when working with individuals that have a diagnosis of dementia. As you see on the screen, these are the assessments that I am going to cover today. 

Allen Cognitive Level Screen-5 (ACLS-5)

Many of us have learned the Allen and know this screen as the ACLS. The most recent version is the fifth edition, which was made available in 2007. Our quick reference name for it would be the ACLS-5 or the LACLS-5, which is for the larger version.

  • Quick reference name: ACLS-5 or LACLS-5
  • ACLS-5 Levels:
    • ACL 3 – Automatic Actions (moderate-severe)
    • ACL 4 – Goal-Directed Actions (mild-moderate)
    • ACL 5 – MCI (mild)
    • ACL 6 – Normal

(Allen et al., 2007)

There are three main categories and Claudia Allen refers to as a level (Allen et al., 2007). The three main levels that I am going to cover are the ACL three, ACL four, and ACL five. ACL three is what we would call automatic actions. ACL four is goal-directed actions, and ACL five is a mild cognitive impairment. Now, if we take those categories from the Allen levels and look at what stage of dementia that actually can correlate with, ACL three is what most of us would refer to as moderate severity up to severe dementia. ACL of four would be goal-directed actions, and that can be known as mild or moderate stage dementia. And then ACL five would be MCI, or what we know as mild cognitive impairment or the mild stage of dementia. ACL six is what we would deem as normal.

The ACLS-5 is used to assess for cognitive impairment. We utilize this with an activities-based measure, and our hope is that this screening tool is easily transportable, allowing us to use it across many different areas of practice. It appeals to most individuals, and it assesses or screens for ACL levels from three to 5.8. There are large and small versions of this, and specific things to consider would be the setup of the stitching and the instructions that are required to deem it standardized when you are delivering this screen.

With each assessment or screening tool, I think it is really important for us, as OTs, to understand that there can be advantages and disadvantages. We also need to understand the administration of the actual tool and what is required. For the Allen Cognitive Level Screen-5, one of the advantages is that it measures various domains. It looks at cognitive, visual motor, and dexterity. Another advantage is that there are online training videos from Allen's Network. The website, allencognitivenetwork.org, has training videos to help you to administer the tool, and it describes best practices and carryover for this specific screening tool. There is no additional certification or training necessary to be able to provide this assessment within your area of practice. There is also a network of research and support, as well as supplies that exist. This is a great central location to meet all of your needs if you utilize this tool. 

There are some disadvantages. It can be time-consuming, depending upon your area of practice and how much time you are allotted for specific things. Another disadvantage is that it can be difficult for those with neurocognitive disorders or advanced physical deficits, and that can provide us skewed results. If the person does not have a cognitive deficit, but they demonstrate dexterity issues or motor planning issues, it could give us a false sense of their cognitive ability.

The administration of the ACLS-5 is anywhere from 15 to 30 minutes. The client performs three different stitches, and each stitch correlates with a varying level of ability.

Allen Diagnostic Module-2nd edition (ADM-2)

The next tool I would like to discuss is the Allen Diagnostic Module, Second Edition.

  • Diagnostic Modules for varying levels
    • Additional options: Allen Placemat Test

(Earhart, 2006)

The diagnostic modules are for varying levels, and they coincide nicely with the ACLS-5. The quick reference name is the ADM. The levels of interest are from level 3.0 to level 5.8 as well. The ADM focuses on task performance, and it provides standardized craft activities. It tests and treats working memory. It also provides a way to verify ACLS scores that were generated from the leather lacing. There is an additional option when using the ADM and that is called the Allen Placemat Test. Some of the positives of the ADM-2 is that it is non-threatening. It is really easy to set up any of the standardized craft activities. It can also be administered in a group format.

One of the advantages of the ADM-2 is that it is standardized. It can be used to validate the ACL level screen. It can be completed with an individual or in a group setting. The ADM-2 is a kit that you can purchase from S&S Worldwide. It provides you all the necessary items, content, and construct validity. It also describes Allen's earlier work on cognitive levels.

One of the disadvantages can be that it relies on a single case method and professional judgment for validity. Another disadvantage is the cost. Because you are working with a standardized tool, you have to purchase all of the items and the kit from S&S. The other disadvantage is that the majority of the crafts are geared towards a 3.6 to a 4.6 cognitive level.

Administration for the ADM could be anywhere from 15 to 30 minutes, depending upon the complexity of the craft, as well as the setting.

Routine Task Inventory-Expanded (RTI-E)

(Katz, 2006)

A quick reference name for this would be the RTI-E. This is able to be downloaded at no cost to the practitioner. This was originally developed by Dr. Katz in 1989 and expanded in 2006. It includes physical, community, communication, and work readiness areas. It is an interview with a checklist that is followed by observations. Scoring is based upon the ACL levels. Thus, being familiar with the ACLS-5, as well as the ADM and the Allen levels, might be helpful if you opt to use this assessment. Some of the positives of this are that it is free and can be self-taught. Some of the considerations are that it requires observation time, and this needs to be completed over a span of time. You need multiple sessions for observing some of the tasks.

One of the advantages is that it is updated, and it has an expanded version from 2006. That is what we are referencing to here. It utilizes the real-life environment for four daily tasks. It is being in the person's actual environment and observing which can be very powerful, as we know.

A disadvantage is the time component. It could take several days to administer.

There are three options for administration, and I will list those three options for you. The first one is a caregiver report. The second option is a self-report, and the third option for administration is the observation of performance.

Global Deterioration Scale (GDS)

Next, we jump into the Global Deterioration Scale.

  • Quick reference name: GDS
  • Stages range from 1 -7
  • Stage 1 = Normal
  • Stage 7 = End-Stage/Severe

(Reisberg, Ferris, DeLeon, & Crook, 1982)

A quick reference name could be the GDS. It ranges from one to seven for staging. This was actually created by Dr. Barry Reisberg in 1984. It was a behavioral-based rating scale, and it is based upon an interview and observation. It was created to assess clinically-identifiable and rateable stages of dementia. Stage one equals normal, and stage seven equals end-stage or severe dementia. There are seven well-defined stages with each stage being described by clinical characteristics. This is available online as a downloadable form: https://www.fhca.org/members/qi/clinadmin/global.pdf.

One advantage of the GDS is that it includes clinical observation, and it allows the OT to assess identifiable things that are based and listed within these stages. There is a very clear description of what is seen, and those correlate with a specific level.

On the flip side, this can also be a disadvantage because some of the characteristics might fall into several categories. Then comes the question of, what stage do we go with? I have found this to be a little frustrating. There can be some similarities and then there are some clear differences within these stages.

The administration is quite nice. It can be 30 to 45 minutes for each scale, and each scale meaning each stage. Within a stage, if you are trying to validate it, it can take 30 to 45 minutes.

Functional Assessment Staging (FAST)

FAST is the quick reference name for the Functional Assessment Staging. This was also created by Dr. Barry Reisberg in 1984. It is also an interview and observation. It was created as an expansion on the GDS so it pairs quite nicely with that to provide us more detail when staging severe dementia. When we are looking closer to the six or seventh level of the GDS, that is when the FAST comes into play. Here is the URL link for you to see the FAST: https://pdfs.semanticscholar.org/825a/2a31ecf3b339edc6433429a8af05e15cbd18.pdf

As I previously said, the FAST was expanded from the GDS. So, the FAST scores correlate with independent measures, and with the MMSE scores, the Mini-Mental State Exam. We will talk about that here in a minute. Another advantage is that the FAST addresses toileting, bathing, IADLS, and mobility. These four additional areas extended the FAST from the GDS.

One of the disadvantages is that the FAST's reliability is dependent upon the Brief Cognitive Rating Scale. There is not a whole lot of individual research just on the FAST, because Dr. Reisberg actually paired his research on the FAST and the Brief Cognitive Rating Scale, as well as the GDS. Thus, a lot of that research is compiled together.

FAST administration is similar to the GDS. The time to administer is 30 to 45 minutes per scale. Remember with the GDS, as well as the FAST, you have to have time to observe as well as complete the interviews.

Cognitive Performance Test (CPT)

The CPT was created by Theressa Burns in 2013. It was originally published in 1984, and in 2002, this is when it was first discussed. The CPT version used in clinics today is most likely the 2013 version. It is standardized graded tasks that look at performance. It is a functional assessment of daily living skills that was originally based upon Allen's Cognitive Levels in 1984, as well as in 2002. The 2013 version was updated to discuss and generate cognitive levels and abilities that reflect function but that are different from the ACL levels. It was to take the original idea of the Cognitive Performance Test and expand and go beyond the ACL levels to really separate from it and develop a new assessment tool. This version looks at someone's function much differently than Allen's levels. This can be purchased from Ableware.

The Cognitive Performance Test has high inter-rater reliability. There have been validity testing that correlates the CPT with the MMSE, the Mini-Mental State Exam. The CPT also corresponds to the occupational profile, and this will allow therapists to have assistance in identifying the client's specific preferences during daily tasks. We are discussing how we want to be client-centered and holistic. Working in dementia care can be a challenge. Using the CPT can help us to focus on the client and their specific preferences during those daily tasks. Another advantage is that it is observational in nature.

One disadvantage is the cost as it is not a downloadable item. It is a kit that you have to purchase. The cost sometimes can be prohibitive for individuals wanting to use it within their clinic or private practice. Time restraints can also be another disadvantage because it is based on the task you are asking the client to do within the CPT. Some of these tasks, depending on the client and their unique concerns that you are working on, could extend how long a specific assessment measure takes. The standardized setup and positioning for each subtest and task can also be a disadvantage because there is a specific way to set up some of the measures. It can be restraining based upon your setting.

You need at least 15 minutes, and perhaps more, depending upon the tasks that you are assessing. You will also need common items like clothing for the ADL portion of the assessment, bread and a toaster for cooking, and other different components for the ADL and IADL skills.

Dynamic Lowenstein Occupational Therapy Cognitive Assessment- Geriatric

The Dynamic Lowenstein Occupational Therapy Cognitive Assessment-Geriatric Version is also called the DLOTCA-G. The LOTCA was created in 1989 to assess cognitive abilities based upon everyday functions that require specific forms of intellect (Katz, Averbuch, & Bar-Haim Erez, 2011). The initial research was generated to demonstrate good inter-rater reliability. Additionally, the LOTCA and the LOTCA-II have been suggested to have positive correlations with the MMSE when used in the same patient populations. The Lowenstein Occupational Therapy Cognitive Assessment was the original assessment. But since then, there have been different versions that have come out, which still have a solid foundation from the LOTCA.

The DLOTCA-G was actually created in 2011. And the purpose of the G, or the geriatric version of the DLOTCA, was to assess individuals that are 70 years or older. There is also just a DLOTCA without the G, and that assesses individuals that are 69 or younger. The DLOTCA-G is actually an activity-based measure. It assesses executive abilities and neurological deficits. The DLOTCA-G has 24 subtests, and the subtests span seven cognitive areas and have an established queuing system. I really think that that is one of its strengths which I will talk about in a minute. Now, the construct validity of the DLOTCA-G compares healthy elders with patients following a dementia diagnosis. And if you are interested in the DLOTCA-G, it can be purchased from Maddak.

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sara story

Sara Story, EdD, OTD, OTR/L, BCG, CAPS

Sara Story, EdD(c), OTD, OTR/L, BCG, CAPS is an occupational therapist and associate professor in the Auerbach School of Occupational Therapy at Spalding University. She is board-certified in gerontology through the American Occupational Therapy Association (AOTA) and Certified Aging in Place Specialist (CAPS) through the National Association of Home Builders (NAHB). Her areas of practice include gerontology and mental health with a research interest in aging in place, community mobility, and mental health services. Sara has published and delivered presentations at the regional, state, and national levels supporting her research and scholarship interests.

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