Author:
Kim Warchol, OTR/L, Founder of Dementia Care Specialists
Let’s start with a question. Would you build a school and plan the curriculum without knowing the ages of the children who planned to attend? Doing so would be akin to opening a senior living facility without knowing the cognitive capacity of those you intend to serve.
Cognition refers to our mental functions such as thinking, reasoning, remembering, learning, and problem solving. Cognitive capacity underlies everything we do and is the basis of our capability to function in the world.
Cognitive capacity changes throughout the life span. At different points in development, cognitive abilities are gained until a person typically reaches their cognitive maturity around the age of 25. It is not uncommon for cognitive ability to decline somewhat in older age. And when diseases strike such as Alzheimer’s, it leads to dementia and a chronic, progressive cognitive decline over time.
1 in 3 seniors die with dementia. Additionally, data from NORC at the University of Chicago indicates that the average assisted living resident is managing more than 14 chronic conditions. The most prevalent? Alzheimer’s disease and other dementias—affecting about 42% of residents.
Because of this high prevalence, it is important for senior living providers to have some understanding of the cognitive ability of their residents, at the time of admission, and it should be routinely monitored in wellness checks.
The Immense Value of Cognitive Levels in Senior Living
In my practice as an occupational therapist, and in the training and tools we have developed at Dementia Care Specialists (DCS), we use the Allen Cognitive Levels to describe cognitive ability across a continuum. These cognitive levels are a key component of DCS’ Dementia Capable Care training program, care system, and consultative services offered to optimize programming and the environment.
There are six Allen cognitive levels with six being normal cognition, five being mild cognitive impairment (common in older age), and one through four being the equivalent of stages of dementia.
In this blog I describe how knowing cognitive level ensures those in care receive the support needed for everyday living and to safely navigate and use their environment.
Applying cognitive levels will help a senior living (IL. AL, and Memory Care) community to:
- Identify a resident’s highest level of independence possible in IADLs, ADLs and leisure activity, and identify the amount and type of care support needed: Apply to create effective care/treatment plans, and to ensure goals and support needs are well understood.
- Predict the amount of staff time required for ADL, IADL, leisure and social support: Apply to staff planning to ensure you have the right number of staff to care for your resident mix.
- Use for acuity-based pricing: Apply to pricing structure for an intuitive business model strategy. Pricing shouldn’t be based on the size or location of the room, alone. Labor is the highest cost of doing business and the support time matters much for positive outcomes. Get it right in the beginning and have a proven method to avoid acuity creep.
- Set admission and discharge requirements: Use the cognitive level as one assessment result to help determine if IL, AL or memory care is the best fit, and use it to help have the conversation about when it is time for someone to transition to the next level of care.
- Design a supportive built environment: The physical environment is a key tool to enable seniors to enjoy and safely engage in life. Use the cognitive level to help make important design decisions that are reliant on cognitive skills such as ability to use navigation signage and technology, ability to manage in room thermostats- even the ability to find and use garbage cans.
Did you know there is a cognitive level cutoff in which someone can look for something (e.g. a garbage can) that is out of line of sight? Therefore, if you put trash cans in cabinets or recessed under a counter, a resident may not be capable of finding it and they might put garbage in other repositories such as a sink or toilet. Cognitive challenges also impact the ability to use elevators, safely access the outdoors, safely use kitchen appliances and knives, etc. - Identify high risks and prevention strategies: We don’t have to wait for accidents and injuries to happen. Use the Allen Cognitive Levels as a tool to predict and prevent high risks such as infections, falls, over or under medicating, car accidents, and elopement. When we see cognitive deficits in one IADL we can assume the person will have challenges with other activities with similar cognitive demand. In other words, if having challenges with one IADL we can expect challenges with all.
- Inform therapy plans: OT, SLP and PTs who are trained in understanding Allen Cognitive Levels are far more effective in their work and can be a valuable resource on the IDT by being the lead professional to assess a person’s cognitive level and to create the care/service plan.
Below I will provide a brief description of each Allen Cognitive Level and demonstrate some application to admission/discharge criteria, level of care needs and risk management. The descriptions below are based purely on cognitive ability/changes.
Allen Cognitive Level 6 – Normal cognition.
- Level of Care: Recommend independent living without any special accommodation.
- Level of Assist: Anticipate independence in IADLs and ADLs.
Allen Cognitive Level 5 – Mild Cognitive Impairment. Experiencing some decline in executive functions such as learning something new and complex, abstract thinking, anticipating consequences, recognizing secondary effects, organizing, and safety awareness and judgment.
- Level of Care: Recommend independent living, with some supervision.
- Level of Assist: Anticipate the ability to be independent in familiar activities, however, will need some supervision and initial cognitive support when/if there is a change in how or where it is usually done.
- Risk Management: Driving may become unsafe.
Allen Cognitive Level 4- Early-Stage Dementia. All executive functions are declining and are now experiencing decline in safely solving problems and in learning something new.
- Level of Care: Recommend assisted living.
- Level of Assist: Needs supervision to minimum cognitive support (staff do about 25%) to do Activities of Daily Living (ADLs) e.g. showering, dressing and grooming) and Instrumental Activities of Daily Living (IADLs) safely and with good quality. (If lower in the early stage, will need even more support.)
- Risk Management: High risks include but are not limited to: UTI’s; accidents which may include injuries due to poor judgment and problem solving.
Allen Cognitive Level 3 – Middle Stage Dementia. This is now a 1:1 care level with step-by-step sequencing cues needed. Learning, problem solving, safety awareness and judgment are all significantly impaired. Attention and communication (receptive and expressive) also impaired.
- Level of Care: Recommend memory care.
- Level of Assist: Requires 1:1 moderate assistance with basic ADLs (staff to do about 50%). Environmental cues such as signage have limited value and thus the resident may be lost (or “wander”) and will need to be accompanied to activities and the dining room.
- Risk Management: High risks include but are not limited to: falls, distress behaviors (e.g. sundowning, agitation, resistance and anxiety), pacing and wandering, unmanaged pain, and excess disability.
Allen Cognitive Level 2 and 1 – Late and End Stage Dementia. In addition to all the cognitive challenges described above, mobility is also declining and communication is extremely limited. In Allen Cognitive Level 2 walking becomes unsafe and by Allen Cognitive Level 1 the person is no longer able to walk and is primarily bedbound. The person at this cognitive level speaks few if any words, communicating primarily through nonverbal methods and behaviors. End of life care becomes important for various reasons including unsafe swallowing, limited mobility, and infections are common.
- Level of Care: Recommend memory care and end of life care (e.g. hospice).
- Level of Assist: Requires staff to provide 1:1 maximum to total assist (staff to do 75-100% of the care).
- Risk Management: High risks include but are not limited to: infection, wounds, aspiration pneumonia, falls, unmanaged pain, and failure to thrive.
Summary
As you can see, Allen Cognitive Levels are as informative as a developmental age telling us the level of functional independence that is possible, guiding the amount and type of care support needed, identifying high risks, and helping us to make the best choices for staffing and creating supportive environments.
Without knowing the Allen Cognitive Level of those you serve in senior living, it is a trial-and-error approach. This leaves the organization and the resident at risk. And the sad part is these risks are often avoidable if the senior living community institutes the best practice of learning and applying the cognitive level of those in their care.
Don’t simply react to problems. Act skillfully and proactively by using cognitive levels as a road map for providing the very best care, as described above.
If your organization needs a cohesive person-centered, cognitive level supportive system, we can help. Our Dementia Capable Care training and care system includes cognitive assessments and care/service plans, and our environmental design services will ensure you are set up to successfully care for elders at all levels of cognitive ability across the senior living continuum.
Gain the knowledge and skills to optimize function, safety, and quality of life for those you serve and certifications to distinguish yourself or your organization as a leader
Originally published May 7, 2026.
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