What to Know About the Allen Cognitive Level Screen (ACLS)

The Allen Cognitive Level Screen (ACLS), which requires a person to do a few short stitching tasks with a string and a needle, is used to screen for dementia. It involves following instructions, using fine motor skills, and learning.

The assessment was created by an educator and occupational therapist named Claudia K. Allen and colleagues. It was first published in 1985 and has been changed several times since then.

In this article, you will learn about the ACLS, including why it is used, what the results can tell you, and how it's different from other cognitive tests.

What Is the ACLS?

Tests that evaluate memory and reasoning are called cognitive tests. Most of these tests ask questions that measure your thinking ability and skills (cognitive function).

The ACLS is different from other cognitive tests. Instead of answering questions, you will do some threading tasks using string, a needle, and a piece of leather with holes around the edges. One side of the string is light-colored and the other is dark-colored.

There are different versions of the test materials:

• A disposable version can be used if someone has an infection that could spread to other people.
• A larger version of the test can be used by people with vision and coordination difficulties.

The ACLS is based on Allen's Cognitive Levels. The levels are on a scale from 0 to 6. Each number is matched to a level of cognitive ability and function.

In general, the ACLS should not take longer than 20 minutes to complete. People with higher cognitive levels will likely finish sooner.

Tasks In the ACLS

The ACLS uses sewing stitches to measure a person's level of cognition. With each step, the tasks require more understanding to complete.

Here is what it's like to do the ACLS test.

• Running stitch: The first task of the ACLS is called the running stitch. First, the person giving the test will show you how to do the stitch. Then, they will ask you to do several of the stitches in a row.
• Whipstitch: Next, the person giving you the test will show you how to do the whipstitch. Then, they will ask you to make several stitches in a row—but with additional rules. You will be asked to keep the light side of the leather string facing up the whole time you are stitching. You also need to make sure the string doesn't get twisted as you stitch. This task is harder than the first because the stitch is more difficult and you also have to keep your eye on the string.
• Error-correcting: For the third task, the person giving you the test will sew the stitch the wrong way. They will make a mistake called the cross-in-the-back error. Then, they will ask you to fix the error. Next, the person will make another stitching error called the twisted lace mistake. They will ask you to find the error and fix it.
• Cordovan stitch: The last stitch you will do is called the single cordovan stitch. Unlike the stitches you already did, the person giving you the test will not show you how to do this stitch. They will just show you what the stitch looks when it's finished. Then, they will ask you to copy the stitch three times.

ACLS Scoring

Your score on the ACLS is based on the number of correct stitches and the difficulty of the stitch. You get more points for doing harder stitches and tasks correctly.

The final scores are turned into numbers that match a certain level. These levels often correspond to how much help a person probably needs to do tasks in their daily lives safely.

The Allen Cognitive Levels are based on a scale of 0 to 6, with 0 being comatose (i.e., unaware of the world around you) and 6 reflecting normal cognition. Scores of the ACLS range only from 3.0 to 5.8. If you're at a cognitive level below 3, you would not be able to do the test.

The test scores stop at 5.8 instead of 6.0 on the higher end because the ACLS does not fully test your ability to plan for the future, which is part of a cognitive assessment.

Allen's Cognitive Levels

Allen's cognitive levels put a person's functioning on a scale of 0 to 6. Each level also corresponds to how much help a person at that level might need to function as well as possible.

The ALCS cannot be used to determine levels below 3 or level 6.

Here are Allen's cognitive levels and what being at each level means.

Level 0: Coma

A score of 0 means that a person is unaware of what's going on around them. They can't move or respond to their environment. This is described as being comatose.

Level 1: Awareness

This level means that cognition and awareness are very impaired. At this level, people will need total care, 24 hours a day.

Level 2: Large Body Movements

This means that a person can move around a little on their own, but still needs 24-hour care.

They would need help with all activities of daily living, such as bathing, eating, and hygiene.

Level 3: Manual Actions

ALCS scores between 3.0 and 3.8 mean a person needs someone to look after them and help with daily activities.

They might need to be cued to do a task. For example, having someone hand them a toothbrush to make sure they brush their teeth.

Level 4: Familiar Activity

If the score is between a 4.0 and a 4.8, it's recommended to have a routine. Safety issues and problem-solving can be hard to manage.

With a score in the higher range of level 4, people might be able to live alone as long as they have a plan for what to do if they need help. For example, if something unexpected happens, they should know to call a loved one for support.

Level 5: Learning New Activity

A score between 5.0 and 5.8 means that cognitive impairment is mild. They can still function well on their own and learn new things.

At the lower range of this level, having weekly check-ins from a loved one or from other community support services can be useful.

A score in the upper range usually means that a person is likely to function well on their own and can do a job well.

Level 6: Planning New Activity

Level 6 is the highest level. This means that there is no apparent impairment of cognitive skills and the person is considered to be normally functioning.

At this level, a person is able to work out problems and make decisions using good judgment. This process is called executive functioning. They also are likely to have complex thought processes that help make plans for the future.

ACLS vs. Other Cognitive Tests

Many assessments and screenings can be used to measure a person's cognitive abilities. Other cognitive tests look at a person's short- and long-term memory. For example, the Mini-Mental Status Exam (MMSE) scores a person's cognitive abilities.

The tests can check for signs of mild cognitive impairment and signs of diseases that cause dementia, like Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementia, residual impairments after moderate or severe traumatic brain injury, and chronic traumatic encephalopathy.

The ACLS is not meant to be a diagnostic test, but it can help providers spot cognitive conditions like dementia. It can be used with other screenings and medical tests in the process of diagnosing these conditions.

Sometimes, a person's score on one cognitive test doesn't match their ability to function in their daily living. This is because a person's cognitive skills are not always used the same way in the practical areas of their life. The ACLS tries to bridge that gap.

How Is This Test Used?

The ACLS is used to help figure out if a person has the thinking and physical abilities to safely do the tasks they need to do every day. This is called functional cognition.

People in different situations can benefit from being tested with the ACLS.

For example:

• An occupational therapist might be asked to give the test to an adult in a nursing home who is recovering from a hip fracture.
• The ACLS can be helpful for people recovering from brain injuries, people in recovery from drug misuse or overdose, and people who have mental health conditions.
• The test may show that person needs someone to make meals for them or give them their medications. Some people may need help handling money or doing chores. Other people need to have care 24 hours a day because it's not safe for them to live alone.
  

How Accurate Is the ACLS?

The results of the ACLS test can often detect potential problems with independence.

The ACLS has also been compared to typical cognitive tests like the Montreal Cognitive Assessment (MoCA) and the MMSE. Researchers have found it to be accurate by using a process called validation.

Pros and Cons of the ACLS

An advantage of the ACLS is that it tests integrated skills, rather than memory or verbal answers to questions.

On the other hand, people with physical limitations may not be able to do the ACLS test. For example, a person needs to be able to use both hands. They also need to have good vision and hearing. In some cases, modified versions of the ACLS (like one with a bigger needle and string that's easier to see) might be available.

The ACLS can also be affected by something called test-retest learning. This means that if you have done the test before, you might be more likely to score higher on it. And people who already know how to do the stitches could also do better on the test.

Summary

The Allen Cognitive Level Screen (ACLS) is one of the tools that's used to help figure out if it's safe for a person to live on their own.

The ACLS is different from other cognitive tests. Instead of asking questions, it has people complete a task with strings. A person's score on the test is related to how well they are able to learn different stitches and do them correctly.

A person's score on the ACLS is more than just a number. Their level also determines how much help they need. Some people may only need a little bit of help from family and friends, while others need someone to care for them all the time.