Rancho Los Amigos Level of Cognitive Functioning Scale: Difference between revisions
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* If the patient becomes agitated: | * If the patient becomes agitated: | ||
** stay with them until they regain control | ** 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. | ||
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Revision as of 03:47, 10 July 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 Scale 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 (2) the level of assistance a patient requires to complete cognitive and physical functions.[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]
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 ADLs |
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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 behaviour rather than on performance-based objective measures.[4]
- Not every patient will fit neatly into a single level. They may show aspects or behaviours 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.[4]
- 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.[5]
- 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.[5]
- 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 MDT, 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 |
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Levels I-III |
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Level IV |
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Levels V-VI |
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Level VII |
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Level VIII |
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Level IX |
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Level X |
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Optional video: after reading the above clinical insights on patient behaviours, please watch this short video and note the use of some of the listed techniques throughout this patient's recovery. The video is provided by Shirley Ryan AbilityLab.
RLAS-R Clinical and Prognostic Value[edit | edit source]
Patients admitted into the healthcare system are becoming more complex. However, healthcare resources are not increasing to support longer or more intensive rehabilitation programmes. A 2023 study by Frantz et al.[4] found that between 40-100% of patients experiencing a brain injury-related coma admitted to the ICU exhibit cognitive impairment regardless of their age at injury. This points to the need for standardised tracking of cognitive outcomes for this patient population to assist with rehabilitation programme planning.[4]
Patients with a TBI can present with wide ranging cognitive deficits following their injury. Those with more severe TBI-related cognitive impairment are more vulnerable to complications, and often require longer ICU admissions. In the long term, more involved TBI-related cognitive impairments can create greater obstacles for reentry and reintegration into the community.[7] A study by Rabinowitz and Levin[7] found that 65% of patients with moderate to severe TBI experienced impaired cognitive functioning which limited their ability to return to their prior level of functioning.
Multiple recent studies have looked into methods, specifically performed by nursing staff in critical care areas, to enhance cognitive recovery in patients following a TBI. These studies found that the implementation of “integrative nursing practices” such as daily music therapy, aromatherapy, and formal cognitive assessment, improved cognitive recovery for patients with TBIs. The use of standardised assessment, such as the Ranchos Scale, allows the MDT to monitor patient recovery and adjust interventions as appropriate to better stimulate affected neural networks, increase brain plasticity, avoid sensory deprivation, and improve patient safety and fall prevention.[7]
There is no single expected outcome or timeframe for recovery following a TBI, but the Ranchos Scale can provide some guidance to an individual patient’s progress. The Ranchos Scale is commonly used due to its simplicity of application and prognostic value related to vocational outcomes.[8]
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]
Additional Resources[edit | edit source]
Clinical Resources:[edit | edit source]
- Rancho Los Amigos Revised Scale (RLAS-R) PDF
- Family Guide to The Rancho Levels of Cognitive Functioning PDF
Optional Recommended Reading:[edit | edit source]
- 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.
- Lin K, Wroten M. Ranchos los amigos. 2022.
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 4.3 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.
- ↑ 5.0 5.1 Schiurring, S. Neuroassessment Programme. Rancho los Amigos Level of Cognitive FunctioningScale. Plus. 2023.
- ↑ YouTube. Brett's Story: Back to College after a Traumatic Brain Injury | Shirley Ryan AbilityLab. Available from: https://www.youtube.com/watch?v=pJlEwRPrI04 [last accessed 29/June/2023]
- ↑ 7.0 7.1 7.2 Othman SY, Mohamed AM, El-Soussi AH, El-Monaem SA, Ahmed FR. Effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients. Journal of Nursing Education and Practice. 2020;10(10):75-89.
- ↑ Masiero S, Cerrel Bazo HA, Rattazzi M, Bernardi L, Munari M, Faggin E, Cattelan M, Pauletto P, Del Felice A. Developing an instrument for an early prediction model of long-term functional outcomes in people with acquired injuries of the central nervous system: protocol and methodological aspects. Neurological sciences. 2021 Jun;42:2441-6.