Rancho Los Amigos Level of Cognitive Functioning Scale: Difference between revisions
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* Thorough documentation will support a single practitioner’s rating and will help track a patient’s recovery progress. | * Thorough documentation will support a single practitioner’s rating and will help track a patient’s recovery progress. | ||
== Clinical Insights on Managing Patient | == Clinical Insights on Managing Patient Behaviours == | ||
Each level of the Ranchos Scale presents with its own assessment and treatment challenges. Every member of the multidisciplinary team, including the family/support members, should understand how best to interact with the patient to promote cognitive recovery. | |||
Levels I-III | {| class="wikitable" | ||
|+ | |||
* Assume the patient can hear and understand you. | !'''Rancho Level''' | ||
** Introduce yourself | !'''Techniques to promote cognitive recovery''' | ||
** Reorient the patient to time/date/situation | |- | ||
|'''Levels I-III''' | |||
| | |||
*Assume the patient can hear and understand you. | |||
*Every time you interact with the patient: | |||
** Introduce yourself | |||
** Reorient the patient to time/date/situation | |||
** Speak in a calm, slow, normal voice | ** Speak in a calm, slow, normal voice | ||
** Use simple instructions and allow them ample time to respond | ** Use simple instructions and allow them ample time to respond | ||
** Use yes/no questions | ** Use yes/no questions | ||
* Play music the patient enjoy for short periods of time ( | * Play music the patient enjoy for short periods of time (Mmximum 5-10 minutes at a time). | ||
* Turn off or lower the lights to decrease extra stimulation and sensory input | * Turn off or lower the lights to decrease extra stimulation and sensory input | ||
* Limit the number of people in the room to no more than | * Limit the number of people in the room to no more than two at any one time | ||
|- | |||
Level IV | |'''Level IV''' | ||
| | |||
* Work in a calm quiet environment | *Work in a calm quiet environment | ||
* Speak in a calm, slow, normal voice | * Speak in a calm, slow, normal voice | ||
* Use simple instructions and allow them time to respond | * Use simple instructions and allow them time to respond (seconds to minutes). | ||
* Gently repeat the instructions as appropriate. | |||
* Focus on one task/question at a time | * Focus on one task/question at a time | ||
* Limit the number of people in the room to no more than two visitor at any one time. | * Limit the number of people in the room to no more than two visitor at any one time. | ||
* If the patient becomes agitated | * Use your clinical judgment during treatment interventions for the number of staff needed for safety, for example therapy co-treatments for patient safety and energy conservation. | ||
* If the patient becomes agitated: | |||
** stay with them until they regain control | |||
** Keep them safe | |||
** Use patient-appropriate calming methods (music, dimmed lighting, soothing touch, deep pressure, etc.) | |||
* Do not react negatively to unexpected behaviors such as shouting, cursing, physical or emotional outbursts or aggression. Gently redirect the patient after helping them regain control. | * Do not react negatively to unexpected behaviors such as shouting, cursing, physical or emotional outbursts or aggression. Gently redirect the patient after helping them regain control. | ||
|- | |||
Levels V-VI | |'''Levels V-VI''' | ||
| | |||
* Poor memory is expected at these stages | *Poor memory is expected at these stages | ||
** Consistently use memory aids such as photo books and journals | ** Consistently use memory aids such as photo books and journals | ||
** Give clues to help them formulate answers, then fill in any missing information | ** Give clues to help them formulate answers, then fill in any missing information | ||
* Redirect inappropriate actions or advances made by the patient | * Redirect inappropriate actions or advances made by the patient | ||
* Use calm and gentle language and tone of voice | * Use calm and gentle language and tone of voice | ||
* Create routines to help the patient to slowly increase their cognitive independence | * Create routines to help the patient to slowly increase their cognitive independence | ||
|- | |||
Level VII | |'''Level VII''' | ||
| | |||
* | *Use clear and consistent words, actions and gestures as patients at this level can take things literally | ||
* | * Create a routine and maintaining a schedule | ||
* | * Utilise memory aids such as lists, calendars, and reminder apps | ||
* Give calm and gentle feedback for any inappropriate | * Give calm and gentle feedback for any inappropriate behaviour | ||
* | * Continue to lack insight and judgment for safety | ||
|- | |||
Level VIII | |'''Level VIII''' | ||
| | |||
* Encourage safe independence at home, work, school | *Encourage safe independence at home, work, school | ||
* Start and continue a daily routine with activities they can do independently and with assistance/ | * Start and continue a daily routine with activities they can do independently and with assistance/supervision | ||
* | * They may still require supervision for some familiar executive tasks | ||
* | * Able to complete familiar activities in a distracting environment for short periods of time, allowing for rest breaks as needed. | ||
* Continue to provide assistance with memory devices as needed | |||
Level IX | |- | ||
|'''Level IX''' | |||
* Challenge | | | ||
* | *Challenge with multitasking/task-switching | ||
* | * Able to use memory devices independently | ||
* May require some assistance with problem-solving and occasional help for socially acceptable behaviour | |||
Level X | |- | ||
|'''Level X''' | |||
* | | | ||
* | *Able to complete pre-injury tasks with extra time and compensatory techniques | ||
* Monitor for physical or mental fatigue as may still require periodic breaks | |||
|} | |||
== RLAS-R Prognostic Value == | == RLAS-R Prognostic Value == |
Revision as of 03:06, 30 June 2023
Original Editor - Venugopal Pawar
Top Contributors - Venugopal Pawar, Stacy Schiurring, Kim Jackson, Jess Bell, Naomi O'Reilly, Redisha Jakibanjar, George Prudden and Amrita Patro
Introduction[edit | edit source]
The Rancho Los Amigos Level of Cognitive Funtioning Scale, commonly known as The Ranchos Scale, is an integral and widely used tool in the cognitive and behavioural assessment of persons following a traumatic brain injury (TBI).
The Ranchos Scale, was originally developed by Dr. Chris Hagen and team in 1972 at the Rancho Los Amigos National Rehabilitation Center in Downey, California. It has since been revised several times to more accurately reflect individuals with more independence at higher levels of cognitive recovery. The original Rancho Los Amigos Scale (RLAS) had 8 levels[1] but was expanded to 10 levels and renamed the Rancho Los Amigos Revised Scale (RLAS-R). The Ranchos scale development is based on assumption that proper observation of the nature and quality of a patient’s behavioural responses can be used to estimate the cognitive level at which the patient is functioning during their recovery from.a TBI. [2]
Ranchos Exam Overview[edit | edit source]
The Ranchos Scale is a widely used standardised measure which describes the cognitive and behavioural patterns commonly observed in patients as they recover from a TBI.
- It takes into consideration both (1) the patient’s state of consciousness and the (2) level of assistance they require to complete cognitive and physical functions when rating the patient.[3]
- It can be completed by any trained healthcare professional.[3]
- It can be used to facilitate communication[3] among the multidisciplinary team (MDT) to better understand the patient’s abilities, impairments, and prognosis, which will aid in the creation of a more holistic and inclusive treatment plan.
- It is often used alongside the Glasgow Coma Scale (GCS) during acute care assessment following the initial injury.[3] However, unlike the GCS, the Ranchos Scale can be used throughout the patient’s recovery and rehabilitation journey.
Scale and Interpretation[edit | edit source]
The current iteration of the Ranchos Scale, the RLAS-R, is a 10-level descriptive scale.[3] Not every patient will fit neatly into a single level, they may show aspects or behaviors of multiple categories at the same time. Not all patients will move forward through the levels in a single direction, some will experience “backslides” while others skip levels all together. Progress and regression along the Scale depend on an individual’s neurorecovery - which can be effected by the quality and intensity of their rehabilitation.[4]
Different levels are given below:
Level | Cognitive response/need of assistance | Clinical Features | |
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Level I | No response/total assistance |
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Level II | Generalised response/total assistance |
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Level III | Localised response/total assistance |
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Level IV | Confused and agitated/max assist |
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Level V | Confused, inappropriate non-agitated/max assist |
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Level VI | Confused, appropriate/ mod assist |
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Level VII | Automatic, appropriate/ min assist for ADL's |
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Level VIII | Purposeful, appropriate/ stand by assist |
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Level IX | Purposeful, appropriate/ stand by assist on Request |
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Level X | Purposeful, appropriate/ modified independent |
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Information provided in the above table adapted from Lin K, Wroten M. Ranchos los amigos. 2022.[3]
Administering the RLAS-R[edit | edit source]
Administering the Ranchos Scale requires practice and mentorship from a healthcare professional experienced in using the Scale. There is also a training manual available for purchase from the Rancho Los Amigos National Rehabilitation Center.
- Administering the Ranchos Scale involves a healthcare professional’s best subjective assessment.
- A score or level is assigned based on the examiner’s subjective assessment of the patient’s behavior rather than on performance-based objective measures.[5]
- Not every patient will fit neatly into a single level, they may show aspects or behaviors of multiple categories at the same time. Not all patients will move forward through the levels in a single direction, some will experience “backslides” while others skip levels all together.[5]
- Progress and regression is dependent upon many factors such as the individual’s neurorecovery, nutrition, sleep, comorbidities,, the quality and intensity of rehabilitation programme etc.[4]
- The real-time nature of therapy interventions provide an ideal opportunity to assess and assign a Ranchos Level based on a patient’s abilities and behaviours from day to day.[4]
- Thorough documentation will support a single practitioner’s rating and will help track a patient’s recovery progress.
Clinical Insights on Managing Patient Behaviours[edit | edit source]
Each level of the Ranchos Scale presents with its own assessment and treatment challenges. Every member of the multidisciplinary team, including the family/support members, should understand how best to interact with the patient to promote cognitive recovery.
Rancho Level | Techniques to promote cognitive recovery |
---|---|
Levels I-III |
|
Level IV |
|
Levels V-VI |
|
Level VII |
|
Level VIII |
|
Level IX |
|
Level X |
|
RLAS-R Prognostic Value[edit | edit source]
There is no single expected outcome or timeframe for recovery following a TBI, but the Ranchos Scale can provide some guidance to a individual patient’s progress.
Psychometric Properties[edit | edit source]
- Interrater reliabilities ranging from 0.87 to 0.94 and test re-test reliability of 0.82.[2]
- Concurrent validity with the Stover Zeiger scale was 0.92[2]
- Predictive validity from admission to discharge 0.57 to 0.68[2]
Links[edit | edit source]
http://www.traumaticbraininjury.com/symptoms-of-tbi/ranchos-los-amigos-scale/ http://www.neuroskills.com/resources/rancho-los-amigos-revised.php
References[edit | edit source]
- ↑ Hagen, C., Malkmus, D., & Durham, P. (1972). Levels of cognitive functioning. Downey, CA: Rancho L.
- ↑ 2.0 2.1 2.2 2.3 Flannery J, Abraham I. Psychometric properties of a cognitive functioning scale for patients with traumatic brain injury. Western journal of nursing research. 1993 Aug;15(4):465-82. available from: https://journals.sagepub.com/doi/10.1177/019394599301500406
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Lin K, Wroten M. Ranchos los amigos. 2022.
- ↑ 4.0 4.1 4.2 Schiurring, S. Neuroassessment Programme. Rancho los Amigos Level of Cognitive FunctioningScale. Plus. 2023.
- ↑ 5.0 5.1 Frantz A, Incio Serra N, Lopez Almendariz A, Duclos C, Owen AM, Blain-Moraes S. Assessing Cognitive Outcomes in Coma Survivors: A Literature Review. Brain Sciences. 2023 Jan;13(1):96.