Rancho Los Amigos Level of Cognitive Functioning Scale: Difference between revisions
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== '''Scale and Interpretation''' == | == '''Scale and Interpretation''' == | ||
The current iteration of the Ranchos Scale, the RLAS-R, is a 10-level descriptive scale.<ref name=":0" /> 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.<ref>Schiurring, S. Neuroassessment Programme. Rancho los Amigos Level of Cognitive FunctioningScale. Plus. 2023.</ref> | The current iteration of the Ranchos Scale, the RLAS-R, is a 10-level descriptive scale.<ref name=":0" /> 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.<ref name=":1">Schiurring, S. Neuroassessment Programme. Rancho los Amigos Level of Cognitive FunctioningScale. Plus. 2023.</ref> | ||
Different levels are given below: | Different levels are given below: | ||
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== Administering the RLAS-R == | == Administering the RLAS-R == | ||
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 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. | ||
Thorough documentation will support a single practitioner’s rating and will help track a patient’s recovery progress. | * 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.<ref name=":3">Frantz A, Incio Serra N, Lopez Almendariz A, Duclos C, Owen AM, Blain-Moraes S. [https://www.mdpi.com/article/10.3390/brainsci13010096 Assessing Cognitive Outcomes in Coma Survivors: A Literature Review]. Brain Sciences. 2023 Jan;13(1):96.</ref> | |||
* 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.<ref name=":3" /> | |||
* 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.<ref name=":1" /> | |||
* 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.<ref name=":1" /> | |||
* Thorough documentation will support a single practitioner’s rating and will help track a patient’s recovery progress. | |||
== Clinical Insights on Managing Patient Behaviors == | |||
As discussed earlier, 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. | |||
Levels I-III: | |||
* Assume the patient can hear and understand you. everytime you interact with the patient: | |||
** Introduce yourself | |||
** Reorient the patient to time/date/situation | |||
** Speak in a calm, slow, normal voice | |||
** Use simple instructions and allow them ample time to respond | |||
** Use yes/no questions | |||
* Play music the patient enjoy for short periods of time (Maximum 5-10 minutes at a time). This can help soothe the patient and reorient them to self. | |||
* 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 2 at any one time | |||
Level IV: | |||
* Work in a calm quiet environment so that the patient does not become distracted during therapy time | |||
* Speak in a calm, slow, normal voice | |||
* Use simple instructions and allow them time to respond - sometimes this can be seconds to minutes of response time. Gently repeat the instruction as appropriate. | |||
* 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. However, use your clinical judgement during treatment interventions for the number of staff needed for safety. Often therapy will initiate co-treatment between multiple disciplines for patient safey and energy conservation during this stage. | |||
* If the patient becomes agitated, stay with them until they regain control. Keep them safe and use calming methods appropriate for that patient such as music, dimmed lighting, soothing touch, deep pressure, etc. This demonstrates the importance of treating therapist consistency to allow them to get to know this patient and develope a good working relationship and understanding. | |||
* 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: | |||
* Poor memory is expected at these stages | |||
** Consistently use memory aids such as photo books and journals | |||
** Give clues to help them formulate answers, then fill in any missing information | |||
** SLP and OT usually lead the way with these interventions. Communication is important with all treating team members to provide a consistent approach. | |||
* Redirect inappropriate actions or advances made by the patient | |||
* Use calm and gentle language and tone of voice | |||
* Create routines to help the patient to slowly increase their cognitive independence | |||
Level VII: | |||
* Your words, actions and gestures must be clear and consistent as patients at this level can take things quite literally | |||
* Having a routine and maintaining a schedule continue to be important | |||
* Utilize memory aids such as lists, calendars, and reminder apps | |||
* Give calm and gentle feedback for any inappropriate behavior | |||
* Be on alert as these patient still lack insight and judgment for safety | |||
Level VIII: | |||
* Encourage safe independence at home, work, school | |||
* 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 | |||
* These patient are able to complete familiar activities in a distracting environment for short periods of time, so allow for rest breaks as needed. | |||
* And you may need to continue to provide help with memory devices | |||
Level IX: | |||
* Challenge them with multitasking/task-switching | |||
* They should be able to use memory device independently | |||
* They may require some assistance with problem solving and occasional help for socially acceptable behavior | |||
Level X: | |||
* These patients should be able to complete pre-injury tasks with extra time and compensatory techniques. Challenge them! | |||
* However, monitor how they are feeling as they may still require periodic breaks for mental or physical fatigue | |||
== RLAS-R Prognostic Value == | |||
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. | 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. | ||
Revision as of 02:47, 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 | |
---|---|---|---|
Level I | No response/total assistance |
|
|
Level II | Generalised response/total assistance |
|
|
Level III | Localised response/total assistance |
|
|
Level IV | Confused and agitated/max assist |
|
|
Level V | Confused, inappropriate non-agitated/max assist |
|
|
Level VI | Confused, appropriate/ mod assist |
|
|
Level VII | Automatic, appropriate/ min assist for ADL's |
|
|
Level VIII | Purposeful, appropriate/ stand by assist |
|
|
Level IX | Purposeful, appropriate/ stand by assist on Request |
|
|
Level X | Purposeful, appropriate/ modified independent |
|
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 Behaviors[edit | edit source]
As discussed earlier, 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. Levels I-III:
- Assume the patient can hear and understand you. everytime you interact with the patient:
- Introduce yourself
- Reorient the patient to time/date/situation
- Speak in a calm, slow, normal voice
- Use simple instructions and allow them ample time to respond
- Use yes/no questions
- Play music the patient enjoy for short periods of time (Maximum 5-10 minutes at a time). This can help soothe the patient and reorient them to self.
- 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 2 at any one time
Level IV:
- Work in a calm quiet environment so that the patient does not become distracted during therapy time
- Speak in a calm, slow, normal voice
- Use simple instructions and allow them time to respond - sometimes this can be seconds to minutes of response time. Gently repeat the instruction as appropriate.
- 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. However, use your clinical judgement during treatment interventions for the number of staff needed for safety. Often therapy will initiate co-treatment between multiple disciplines for patient safey and energy conservation during this stage.
- If the patient becomes agitated, stay with them until they regain control. Keep them safe and use calming methods appropriate for that patient such as music, dimmed lighting, soothing touch, deep pressure, etc. This demonstrates the importance of treating therapist consistency to allow them to get to know this patient and develope a good working relationship and understanding.
- 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:
- Poor memory is expected at these stages
- Consistently use memory aids such as photo books and journals
- Give clues to help them formulate answers, then fill in any missing information
- SLP and OT usually lead the way with these interventions. Communication is important with all treating team members to provide a consistent approach.
- Redirect inappropriate actions or advances made by the patient
- Use calm and gentle language and tone of voice
- Create routines to help the patient to slowly increase their cognitive independence
Level VII:
- Your words, actions and gestures must be clear and consistent as patients at this level can take things quite literally
- Having a routine and maintaining a schedule continue to be important
- Utilize memory aids such as lists, calendars, and reminder apps
- Give calm and gentle feedback for any inappropriate behavior
- Be on alert as these patient still lack insight and judgment for safety
Level VIII:
- Encourage safe independence at home, work, school
- 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
- These patient are able to complete familiar activities in a distracting environment for short periods of time, so allow for rest breaks as needed.
- And you may need to continue to provide help with memory devices
Level IX:
- Challenge them with multitasking/task-switching
- They should be able to use memory device independently
- They may require some assistance with problem solving and occasional help for socially acceptable behavior
Level X:
- These patients should be able to complete pre-injury tasks with extra time and compensatory techniques. Challenge them!
- However, monitor how they are feeling as they may still require periodic breaks for mental or physical fatigue
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.