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.

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 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.
• 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 is dependent upon many factors such as the individual’s neurorecovery, nutrition, sleep, comorbidities,, the quality and intensity of rehabilitation programme etc.
• 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.
• 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.

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