Rancho Los Amigos Level of Cognitive Functioning Scale

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

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 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.

Ranchos Exam Overview

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. 
• It can be completed by any trained healthcare professional.
• It can be used to facilitate communication 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.  However, unlike the GCS, the Ranchos Scale can be used throughout the patient’s recovery and rehabilitation journey.

Scale and Interpretation

The current iteration of the Ranchos Scale, the RLAS-R, is a 10-level descriptive scale. 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.

Different levels are given below:

Level	Cognitive response/need of assistance	Clinical Features
Level I	No response/total assistance	no response to external stimuli
Level II	Generalised response/total assistance	respond inconsistently and non-purposefully to external stimuli responses are often the same regardless of the stimulus applied
Level III	Localised response/total assistance	respond inconsistently and specifically to external stimuli responses are directly related to the stimulus tend to be more responsive to familiar people (friends and family) than to strangers
Level IV	Confused and agitated/max assist	individual is in a hyperactive state with bizarre and non-purposeful behaviour demonstrate agitated behaviour that originates more from internal confusion than the external environment
Level V	Confused, inappropriate non-agitated/max assist	individual show an increase in consistency with following and responding to simple commands, their responses are non-purposeful and random to more complex commands behaviour and verbalization are often inappropriate, and the patient can appear confused and often confabulates individual can perform an action or task if it is first modeled or demonstrated for them, they do not yet initiate tasks on own memory is severely impaired and learning new information is difficult can show agitation to unpleasant external stimuli
Level VI	Confused, appropriate/ mod assist	able to follow simple commands consistently able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however are unable to retain learning for new tasks demonstrate an increased awareness of self, situation, and their environment but are unaware of any specific impairments and safety concerns responses may be incorrect secondary to memory impairments but appropriate to the situation
Level VII	Automatic, appropriate/ min assist for ADL's	oriented in familiar settings able to perform a daily routine automatically with absent to minimal confusion demonstrate carry over for new tasks and learning in addition to familiar tasks can be superficially aware of diagnosis but unaware of specific impairments continue to demonstrate a lack of insight, decreased judgment and safety awareness beginning to show interest in social and recreational activities in structured settings require at least minimal supervision for learning and safety purposes.
Level VIII	Purposeful, appropriate/ stand by assist	consistently oriented to person, place, and time  can independently carry out familiar tasks in a non-distracting environment beginning to show awareness of their specific impairments and how they interfere with tasks, however, they still require stand by assistance with compensatory skills able to use assistive memory devices to recall a daily schedule acknowledge other people’s emotional states and require only minimal assistance to respond appropriately demonstrate improvement of memory and ability to consolidate past and future event often depressed, irritable, and demonstrate a low threshold to frustration
Level IX	Purposeful, appropriate/ stand by assist on Request	able to shift between different tasks and complete them independently aware of and acknowledge their impairments when they interfere with tasks able to use compensatory strategies to cope able to independently anticipate obstacles that may arise secondary to any lingering impairments able to consider the consequences of actions and decisions with assistance continue to demonstrate depression and low frustration thresholds
Level X	Purposeful, appropriate/ modified independent	able to multitask in many different environments with extra time for task completion or devices to assist able to create their own methods and tools for memory retention can independently anticipate obstacles that may occur as a result of their impairments and take corrective actions able to independently make decisions and act appropriately but may require more time or compensatory strategies may still demonstrate intermittent periods of depression and a lowered threshold for frustration when under stress able to appropriately interact with others in social situations

Information provided in the above table adapted from Lin K, Wroten M. Ranchos los amigos. 2022.

Level I: No Response: Total Assistance

• No response to external stimuli

Level II: Generalized Response: Total Assistance

• Responds inconsistently and non-purposefully to external stimuli
• Responses are often the same regardless of the stimulus

Level III: Localized Response: Total Assistance

• Responds inconsistently and specifically to external stimuli
• Responses are directly related to the stimulus, for example, patient withdraws or vocalizes to painful stimuli
• Responds more to familiar people (friends and family) versus strangers

Level IV: Confused/Agitated: Maximal Assistance

• The individual is in a hyperactive state with bizarre and non-purposeful behavior
• Demonstrates agitated behavior that originates more from internal confusion than the external environment
• Absent short-term memory

Level V: Confused, Inappropriate Non-Agitated: Maximal Assistance

• Shows increase in consistency with following and responding to simple commands
• Responses are non-purposeful and random to more complex commands
• Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates
• If action or tasks is demonstrated individual can perform but does not initiate tasks on own
• Memory is severely impaired and learning new information is difficult
• Different from level IV in that individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli.

Level VI: Confused, Appropriate: Moderate Assistance

• Able to follow simple commands consistently
• Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks
• Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns
• Responses may be incorrect secondary to memory impairments but appropriate to the situation

Level VII: Automatic, Appropriate: Minimal Assistance for Daily Living Skills

• Oriented in familiar settings
• Able to perform
• Daily routine automatically with minimal to absent confusion
• Demonstrates carry over for new tasks and learning in addition to familiar tasks
• Superficially aware of one’s diagnosis but unaware of specific impairments
• Continues to demonstrate lack of insight, decreased judgment and safety awareness
• Beginning to show interest in social and recreational activities in structured settings
• Requires at least minimal supervision for learning and safety purposes.

Level VIII: Purposeful, Appropriate: Stand By Assistance

• Consistently oriented to person, place and time
• Independently carries out familiar tasks in a non-distracting environment
• Beginning to show awareness of specific impairments and how they interfere with tasks, however, requires standing by assistance to compensate
• Able to use assistive memory devices to recall daily schedule
• Acknowledges other’s emotional states and requires only minimal assistance to respond appropriately
• Demonstrates improvement of memory and ability to consolidate the past and future events
• Often depressed, irritable and with low frustration threshold

Level IX: Purposeful, Appropriate: Stand By Assistance on Request

• Able to shift between different tasks and complete them independently
• Aware of and acknowledges impairments when they interfere with tasks and able to use compensatory strategies to cope
• Unable to independently anticipate obstacles that may arise secondary to impairment
• With assistance able to think about consequences of actions and decisions
• Acknowledges the emotional needs of others with stand by-assistance.
• Continues to demonstrate depression and low frustration threshold

Level X: Purposeful, Appropriate: Modified Independent

• Able to multitask in many different environments with extra time or devices to assist
• Able to create own methods and tools for memory retention
• Independently anticipates obstacles that may occur as a result of impairments and take corrective actions
• Able to independently make decisions and act appropriately but may require more time or compensatory strategies
• Demonstrate intermittent periods of depression and low frustration threshold when under stress
• Able to appropriately interact with others in social situations

Psychometric Properties

• Interrater reliabilities ranging from 0.87 to 0.94 and test re-test reliability of 0.82.
• Concurrent validity with the Stover Zeiger scale was 0.92
• Predictive validity from admission to discharge 0.57 to 0.68

Links

http://www.traumaticbraininjury.com/symptoms-of-tbi/ranchos-los-amigos-scale/ http://www.neuroskills.com/resources/rancho-los-amigos-revised.php