Rancho Los Amigos Level of Cognitive Functioning Scale

Original Editor - Venugopal Pawar

Top Contributors - Venugopal Pawar, Stacy Schiurring, Kim Jackson, Jess Bell, Redisha Jakibanjar, Naomi O'Reilly, Amrita Patro and George Prudden  

Introduction

The Rancho Los Amigos Level of Cognitive Funtioning Scale, commonly known as The Rancho(s) Scale, is an integral and widely used tool in the cognitive and behavioural assessment of persons following a traumatic brain injury (TBI).

The Rancho 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 Rancho 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.

Rancho Scale Overview

The Rancho 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. 
• 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 Rancho Scale can be used throughout the patient’s recovery and rehabilitation journey.

Scale and Interpretation

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

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	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	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 verbalisation are often inappropriate, and the patient can appear confused and often confabulates Can perform an action or task if it is first modelled or demonstrated for them, they do not yet initiate tasks on their 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) but 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 ADLs	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, but 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 rustration
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 Rancho 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 Rancho 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.
• 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. 
• 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 Behaviours

Each level of the Rancho 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
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 use simple instructions and allow them ample time to respond use yes/no questions Play music the patient enjoys for short periods of time (maximum 5-10 minutes at a time).  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 two at any one time
Level IV	Work in a calm quiet environment Speak in a calm, slow, normal voice 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 Limit the number of people in the room to no more than two visitor at any one time.  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.
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 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	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 behaviour Provide supervision as the patient can continue to 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 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	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	Able to complete pre-injury tasks with extra time and compensatory techniques Monitor for physical or mental fatigue as may still require periodic breaks

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

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. 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.

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. A study by Rabinowitz and Levin 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 Rancho 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.

There is no single expected outcome or timeframe for recovery following a TBI, but the Rancho Scale can provide some guidance to an individual patient’s progress. The Rancho Scale is commonly used due to its simplicity of application and prognostic value related to vocational outcomes.

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

Additional Resources

Clinical Resources:

• Rancho Los Amigos Revised Scale (RLAS-R) PDF
• Family Guide to The Rancho Levels of Cognitive Functioning

Optional Recommended Reading:

• 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.