Relationship Between the Allen Cognitive and the Rancho Los Amigos Cognitive Levels
Deborah Voydetich, OTR, Michael Jensen, OTS
Barbara Sigford, MD, Ph.D., Julie Mehr, OTR
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Deborah Voydetich received a bachelor of science degree in Occupational Therapy from the University of Minnesota in 1984. Her experience has been in general rehabilitation with emphasis in the treatment of traumatic brain injury and other neurological conditions. She is currently employed at the Minneapolis Veterans Administration Medical Center working with the Defense and Veteran's Head Injury Program.

Michael Jensen is a student at the University of Minnesota, enrolled in the Occupational Therapy Program.

Barbara Sigford, M.D., Ph.D., is currently Director of Physical Medicine and Rehabilitation at the Minneapolis VAMC. She has been the Principle Investigator for the DVHIP at Minneapolis since the inception of the program. She is also Medical Director of the CARF accredited Traumatic Brain Injury Program at the Minneapolis VAMC,
and provides daily care to TBI patients. She is a clinical Assistant Professor at the University of Minnesota and Co-Director of the PM&R Residency Training Program.

Julie Mehr received a bachelor of science degree in Occupational Therapy from the University of Minnesota in 1984. Her experience has been in general rehabilitation with emphasis in the treatment of traumatic brain injury and other neurological conditions. She is currently employed at the Minneapolis Veterans Administration Medical Center working with the Defense and Veteran's Head Injury Program.

ABSTRACT

This study examines the relationship between the Rancho Los Amigos Cognitive Levels (RLA) and the Allen Cognitive Level (ACL) scores. Forty-three inpatient and outpatients with traumatic brain injury (TBI) at the Veterans Affairs Medical Center participated in the study. The ACL was administered by an Occupational Therapist during the initial evaluation sessions and Rancho levels were determined at the same time by TBI
team members. The Rancho Los Amigos levels ranged from V to IX and the Allen Cognitive Level scores ranged from 3.3 to 5.8. A Spearman rho correlation of r=.591 was found, indicating a moderate, positive relationship between the two measures. This poster will present the two cognitive level systems and show how, as evidenced by this study, the Rancho levels may be looked at in terms of functional abilities and predicting the amount of supervision and assistance needed at each level. This study also suggests how these two cognitive tests can complement one another when used concurrently.

INTRODUCTION

The Rancho Los Amigos Levels of Cognitive Functioning (Figure 1) is a behavioral rating scale for assessment of cognitive functioning in adults with TBI (Hagen, Malkmus, and Durham, 1979). It was developed by an interdisciplinary team based on their observations of 1,000 patients during recovery following TBI (Malkmus, Booth, and Kodimer, 1980). Initially, the RLA included levels I-VIII, although, in 1998, the third edition was developed and expanded to included levels IX-X. ( Hagen, 1998) The Rancho levels are widely used by clinicians at many centers for classifying patients for treatment and tracking their progress throughout recovery (Dowling, 1985). RLA is an assessment tool or scale that does not require cooperation from the patient. Patients are classified into levels based on observation of the patient as he responds to the environment. Behaviors are ordered in a hierarchical manner, i.e., low levels of functioning have lower numbers, ranging from no response (level I) to purposeful and appropriate (level X) behavior. The level assigned to individuals provided clinicians with clear description of the patient’s behavior
and is used as a means to develop “level-specific” treatment interventions.

Gouvier, Blanton, Laporte, and Nepomuceno, (1987) found the RLA to have interrater reliabilities ranging from .87 to .94 (M= .89) and test-retest reliability of .82. Concurrent validity with the Stover-Zieger Scale was .92
and predictive validity from admission to discharge ranged from .57 to .68.

Cognitive function can also be measured by the Allen Cognitive Level Assessment, developed by Claudia Allen (Allen 1985). Allen reasoned that the disease-related impairment in the ability to perform routine tasks is a reflection of cognitive disability and identified six hierarchical levels of function. The ACL test was revised in 1990, to include a 25-point scale ranging from 3.0 to 5.8. The revised ACL referred to as the ACL-90 was used in this investigation (Allen, 1990). The ACL is a relatively quick screening tool, administered by an occupational therapist, requiring a patient to perform a sensory motor task (leather stitching) of increasing complexity, which will yield a single score. The test score is derived from an assessment of the subject’s ability to duplicate stitches modeled by the therapist. The ACL score is used to predict both the level of assistance that a given patient will need to perform routine tasks and how that patient will perform in novel situations. (Velligan, 1995).

The ACL has been used extensively with a variety of psychiatric and geriatric populations. Mayer (1988) found a significant relationship between the original ACL and the Wechsler Adult Intelligence Scale (WAIS-R) subtests that measure fluid abilities such as Block Design and Object Assembly subtest (r=.729) and Performance Scale IQ (r=.551) in adult psychiatric population. Velligan et al., (1998) found the reliability of the ACL between two raters on a series of 10 assessments to be high (ICC=.85). Velligan et al., (1998) also revealed positive relationships between the ACL obtained at discharge and community functioning at follow up for patients with schizophrenia.

PURPOSE

Use of the ACL in conjunction with the Rancho Levels may assist clinicians in making decisions about the level of supervision and the amount of assistance needed at each level of recovery. Findings may provide validation to use the ACL with the traumatic brain injury population.

METHOD

Participants:
• Consent and surrogate consent forms from the study, “Comparability of the Allen Cognitive Level Test (ACL-90) with the Large version of the ACL (LACL) with Traumatic Brain Injury” were obtained
• 43 inpatients and outpatients diagnosed with traumatic brain injury at the Minneapolis Veterans Affairs Medical Center
• Age ranged from 18 to 80 years old, (mean = 39)
• 41 males and 2 females
• 32 were tested within 3 months of injury, 6 were tested within 1 year of injury, and the remaining 5 were up to 14 years post injury

Measurement tools:
• The Rancho Los Amigos Cognitive Scale (Figure 1)
• The Allens Cognitive Levels (ACL) Assessment (Figure 2)
• Photo of Allens Cognitive leather lacing task (Figure 3)

Procedure:
• The ACL was administered by an Occupational Therapist during the initial evaluation session. The Rancho levels were determined concurrently by TBI team members.

Results:
• N=43
• Number of subjects at each Rancho level, ACL score range, and mean ACL score are demonstrated in Table 1
• Scattergram and scores are represented in Table 2
• A Spearman rho correlation was performed and found to have a correlation of r=.591, indicating a moderate
positive relationship between the two measures

DISCUSSION

• Further observation of the scattergram reveals several outlying scores that do not follow a linear pattern.
For example, a particular patient functioning at Rancho Level 8 scored a 3.3 on his ACL, indicating a severe
functional decline. Further investigation of individual score reveals a possible explanation. The patient whose ACL scores were lower than expected also displayed significant visual perceptual deficits. The deficits likely impacted performance on the leather lacing task. If this score is eliminated from the analysis, the correlation improves to r=.679. Therefore, the ACL scores may not be as reliable when used with patients experienc- ing visual perceptual deficits.

• The results of the study suggest that the ACL can provide additional information on supervision and amount of assistance needed for functional tasks. Suggestions follow:

• While these results need to be interpreted cautiously due to the relatively small sample size, the results of the study are an important step toward the validation of the ACL in the TBI population. However, further research in validating the ACL and RLA is needed. Additional studies are needed to examine the fit between patients’ ACL scores and their actual placement related to outcomes for TBI patients.

REFERENCES

Allen, C. (1982). Independence through activity: The practice of occupational therapy. The American Journal of Occupational Therapy, 36, 731-739.

Allen, C., (1985). Occupational therapy for psychiatric diseases: Measurement and management of cognitive disabilities. Boston: Little, Brown.

Allen, C.K., & Allen, R.E. (1987). Cognitive disabilities: Measuring the social consequences of mental disorders. Journal of Clinical Psychiatry, 48, 185-190.

Allen, C.K. (1990). Allen Cognitive Level (ACL) Test: Test. Colchester, CT: S&S/Worldwide.

Allen, C.K., (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. American Occupational Therapy Association, Inc. Rockville, MD.

Allen, C. (1995). Occupational therapy for psychiatric diseases: Measurement and management of cognitive diseases. Boston: Little Brown.

Dowling, G., (1985). Level of cognitive functioning: Evaluation of Interrater reliability. Journal of Neurosurgical Nursing, 17, 129-134.

Gouvier, W., Banton, P., Laporte, K., Nepomuceno, C., (1987). Reliability and validity of the disability rating scale and the levels of cognitive functioning scale in monitoring recovery from severe head injury. Archives of Physical Medicine and Rehabilitation, 68, 94-97.

Hagen, C., Malkmus, D., & Durham, P., (1979). Levels of cognitive functioning. Rehabilitation of the head injuried adult: Comprehensive physical management, Dowey, CA: Professional Staff Association of the Rancho Los Amigos Hospital, Inc.

Hagen, C., (1998). Levels of cognitive functioning. Rehabilitation of the head injuried adult: Comprehensive physical management, Third edition, Dowey, CA: Professional Staff Association of the Rancho Los Amigos Hospital, Inc.

Henry, A., Moore, K., Quinlivan, M., Triggs, M., (1998). The relationship of the Allen Cognitive Level Test to demographics, diagnosis, and disposition among psychiatric inpatients. The American Journal of Occupational Therapy 52, 638-643.

Malkmus, D., Booth, B., Kodimer, C., (1980). Rehabilitation of the head injuried adult: Comprehansive cognitive management. Downey, CA: Professional Staff Association of the Rancho Los Amigos Hospital Inc.

Mayer, M.A. (1988). Analysis of information processing and cognitive disability theory. The American Journal of Occupational Therapy, 42, 176-183.
Penny, N.H., Mueser, K.T., & North C.T. (1995). The Cognitive Level Test and social competence in adult psychiatric patients. The American Journal of Occupational Therapy, 49, 420-427.
Velligan, D., True, J., Lefton, R., Moore, C., Flores, C. (1995). Validity of the Allen Cognitive Levels Assessment: a tri-ethnic comparison. Psychiatry Research, 56, 101-109.
Velligan, D., Bow Thomas, C., Mahurin, A., Dassori, A., Erdely, F., (1998). Concurrent and predictive validity of the Allen Cognitive Levels Assessment. Psychiatry Research, 80, 287-98.

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