Rancho Los Amigos Scale

What Is The Rancho Los Amigos Scale?

The Rancho Los Amigos Scale identifies eight levels of post-brain injury cognitive functioning and is utilized by medical staff to evaluate a brain injury patient’s level of brain damage and recovery prognosis.

The scale was developed by head injury treatment staff at the Rancho Los Amigos National Rehabilitation Center to assess the level of cognitive function in brain injury patients.

Rancho Los Amigos Levels of Cognitive Functioning

Level I – No Response
  • Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.
Level II – Generalized Response
  • Demonstrates generalized reflex response to painful stimuli.
  • Responds to repeated auditory stimuli with increased or decreased activity.
  • Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.
  • Responses noted above may be same regardless of type and location of stimulation.
  • Responses may be significantly delayed.
Level III – Localized Response
  • Demonstrates withdrawal or vocalization to painful stimuli.
  • Turns toward or away from auditory stimuli.
  • Blinks when strong light crosses visual field.
  • Follows moving object passed within visual field.
  • Responds to discomfort by pulling tubes or restraints.
  • Responds inconsistently to simple commands.
  • Responses directly related to type of stimulus.
  • May respond to some persons (especially family and friends) but not to others.
Level IV – Confused/Agitated
  • Alert and in heightened state of activity.
  • Purposeful attempts to remove restraints or tubes or crawl out of bed. May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request.
  • Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
  • Absent short-term memory.
  • May cry out or scream out of proportion to stimulus even after its removal.
  • May exhibit aggressive or flight behavior.
  • Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
  • Unable to cooperate with treatment efforts.
  • Verbalizations are frequently incoherent and/or inappropriate to activity or environment.
Level V – Confused, Inappropriate Non-Agitated
  • Alert, not agitated but may wander randomly or with a vague intention of going home.
  • May become agitated in response to external stimulation, and/or lack of environmental structure.
  • Not oriented to person, place or time.
  • Frequent brief periods, non-purposeful sustained attention.
  • Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
  • Absent goal directed, problem solving, self-monitoring behavior.
  • Often demonstrates inappropriate use of objects without external direction.
  • May be able to perform previously learned tasks when structured and cues provided.
  • Unable to learn new information.
  • Able to respond appropriately to simple commands fairly consistently with external structures and cues.
  • Responses to simple commands without external structure are random and non-purposeful in relation to command.
  • Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
  • Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.
Level VI – Confused, Appropriate
  • Inconsistently oriented to person, time and place.
  • Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
  • Remote memory has more depth and detail than recent memory.
  • Vague recognition of some staff.
  • Able to use assistive memory aide with maximum assistance.
  • Emerging awareness of appropriate response to self, family and basic needs.
  • Moderate assist to problem solve barriers to task completion.
  • Supervised for old learning (e.g. self care).
  • Shows carry over for relearned familiar tasks (e.g. self care).
  • Maximum assistance for new learning with little or no carry over.
  • Unaware of impairments, disabilities and safety risks.
  • Consistently follows simple directions.
  • Verbal expressions are appropriate in highly familiar and structured situations.
Level VII – Automatic, Appropriate
  • Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time.
  • Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.
  • Minimal supervision for new learning.
  • Demonstrates carryover of new learning.
  • Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.
  • Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.
  • Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs.
  • Minimal supervision for safety in routine home and community activities.
  • Unrealistic planning for the future.
  • Unable to think about consequences of a decision or action.
    Overestimates abilities.
  • Unaware of others’ needs and feelings.
  • Oppositional/uncooperative.
  • Unable to recognize inappropriate social interaction behavior.
Level VIII – Purposeful, Appropriate
  • Consistently oriented to person, place and time.
  • Independently attends to and completes familiar tasks for 1 hour in distracting environments.
  • Able to recall and integrate past and recent events.
  • Uses assistive memory devices to recall daily schedule, “to do” lists and record critical information for later use with stand-by assistance.
  • Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
  • Requires no assistance once new tasks/activities are learned.
  • Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
  • Thinks about consequences of a decision or action with minimal assistance.
  • Overestimates or underestimates abilities.
  • Acknowledges others’ needs and feelings and responds appropriately with minimal assistance.
  • Depressed.
  • Irritable.
  • Low frustration tolerance/easily angered.
  • Argumentative.
  • Self-centered.
  • Uncharacteristically dependent/independent.
  • Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Original Rancho Los Amigos Cognitive Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A., Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.

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