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Rancho Los Amigos Levels

of Cognitive Functioning

 

Feb. 28, 2010: President Obama visits Cory Remsburg at the National Naval Medical Center in Bethesda, Md. (Official White House Photo by Pete Souza)

The Rancho Los Amigos Levels of Cognitive Functioning scale was developed in 1972 by Chris Hagen, PhD, Danese Malkmus, M.A. and Patricia Durham, M.A. of the Communications Disorders Services Department of Rancho Los Amigos National Rehabilitation Center in Downey, California. The scale was revised in 1974 by Danese Malkmus, M.A. and Kathryn Stenderup, O.T.R. and again in 1997 by Chris Hagen, PhD. The Rancho Los Amigos levels are designed to indicate the behavior and progression of function as the brain injury patient participates in treatment. They apply to the first few months following brain injury and are not meant to predict long term recovery. Patients may display characteristics of more than one level at a time.

4 creative ways of remembering the Rancho Los Amigos Levels

 

Number 1.

This is a fun way of associating the levels of the Rancho Los Amigos with the stages of child development. The information has been taken from:
http://doccartoon.blogspot.com/2012/03/rancho-los-amigos.html

 

Rancho I: No Response
– appears to be in a deep sleep, completely unresponsive to stimuli.
Stage of child development: Embryo

 

Rancho II: Generalized Response (vegetative state)
–responses may be physiological changes, gross body movements.
Stage of child development: Fetus

 

Rancho III: Localized Response (minimally conscious state)
–responses are directly related to the type of stimulus presented.
Stage of child development: Newborn

 

Rancho IV: Confused/Agitated
–may cry out or scream
–unable to cooperate
Stage of child development: Terrible 2’s

 

Rancho V: Confused, Inappropriate Non-Agitated
–can usually perform self-care activities, with assistance.
Stage of child development: 3 or 4-year-old

 

Rancho VI: Confused, Appropriate
–follows simple directions consistently and shows carry-over for tasks.
Stage of child development: 5 or 6-year-old

 

Rancho VII: Automatic, Appropriate
–initiates tasks such as social or recreational activities
Stage of child development: 7-10-year-old

 

Rancho VIII: Purposeful, Appropriate
–independent in home and community skills, including driving.
 Stage of child development: Teenager

 

 

Number 2.

Grouping the levels according to level of assistance.


   1,2,3   Total Assistance

     4,5    Maximal Assistance

        6    Moderate Assistance

        7    Minimal Assistance

        8    Stand By Assistance

        9    Stand By Assistance on Request

      10    Modified Independent

 

Number 3.
The Rancho Los Amigos Levels review (The OT Minute)

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Number 4.

A Synopsis of Levels 1 – 8

 

LEVELS

1- 3

 

TOTAL ASSIST
Low motor movement
Limited response to stimulation
…..
Level 1– appears asleep
Level 2– generalized response
Level 3- localized response: turns to or away, may blink or follow object

.
LEVELS

4 – 6

MAX ASSIST (levels 4 and 5) and MODERATE ASSIST (level 6)
Confused
No learning
Non-goal oriented
 
Level 4 – confused/agitated, aggressive, may crawl out of bed
Level 5 – confused with agitation, inappropriate behavior, max assist with highly familiar tasks
Level 6 – confused but appropriate behaviors, moderate assist with tasks, awareness up to 30 mins…..

.
LEVELS

7 – 8

MIN ASSIST (level 7) and SB ASSIST (level 8)
Automatic
New learning
Correct behavior with assistance
 
Level 7 – automatic, appropriate, attends to familiar tasks up to 30 mins.
                unrealistic, unaware of others
                new learning with carry over
Level 8 – Purposeful/appropriate. attends up to 1 hour. Uses lists.

..
.

 

A comprehensive table outlining the 10 Rancho Los Amigos levels

Level/ Description Amount of Assistance Behaviors and Abilities Function: at this level, a person will display these responses. Occupational Therapy Treatment Video Links
I – No Response

Total Assistance No observable change in behavior when presented with any kind of stimuli. No response to any kind of stimuli, including visual, auditory or tactile input or movement. -Passive range of motion

-Splinting and positioning to manage contractures

-Sensory stimulation

Demonstration of Level I
II – Generalized Response

 

Total Assistance -Generalized reflex responses to pain

-Generalized activity responses to sound or other external stimuli

-Responses may be delayed and may be the same regardless of stimuli

Begins to respond to sensory stimuli, including visual, auditory or tactile input or movement

-Responses are inconsistent

-Responses are the same to all types of stimuli

-Responses are not purposeful

-Responses may include chewing, sweating, changes in respiration rate, increased blood pressure, or others.

-Passive range of motion

-Splinting and positioning to manage contractures

-Sensory stimulation

Demonstration of Level II
III – Localized Response

 

Total Assistance -Reacts to pain by withdrawing or moaning

-Blinks at strong light and follows moving objects

-Turns toward sound

-May pull at tubes or restraints

-May respond to simple commands

-May respond to family or friends but not other people

1. Awake on and off

2. Displays more movement

3. Starts reacting more specifically to different types of stimuli
-jumps at loud noise or withdraws from pain
-turns head to look at specific people or objects
-turns head in the direction of noise

* *reactions are slow and inconsistent

4. Begins to respond to family and friends.

5. Responds to simple instructions

6. Begins to answer simple yes and no questions

-Passive range of motion

-Sensory stimulation

-Visual and auditory tracking activities

-Adaptations for safety and restraint reduction

Demonstration of Level III
IV – Confused/Agitated

 

A C C C CCCCCCCCCCCCCCCCCCCCCCCCCCCC

Maximal Assistance -Alert

-Heightened state of activity, may move constantly, movements not purposeful

Crying out or screaming in reaction to stimuli, out of proportion to stimuli

May run away or become aggressive

Extreme mood swings with no relation to environment

-No short term memory

-Unable to cooperate with treatment

-Verbalizations usually incoherent or inappropriate

1. Displays confusion and fear

2. Does not understand feelings or what is happening in surroundings
-may not understand that other people are providing help

3. Responds to stimuli by acting out
– hitting, yelling or screaming, using abusive language
-extreme behavior due to confusion
-may need restraints to avoid self injury

4. Overly focused on basic needs, such as eating, going to the bathroom, etc.

5. Displays difficulty attending for more than a few seconds

6. Has difficulty following directions

7. Recognizes family and friends inconsistently

8. Completes simple, routine tasks with assistance

-Active or active assistive range of motion as person will tolerate

-Simple reaching activities
-Simple cognitive activities such as picture or object identification
-Participate in simple activities of daily living with assistance, i.e. washing face, brushing hair, self feeding

Demonstration of Level IV
V – Confused, Inappropriate Non-agitated

 

Maximal Assistance -Alert, not agitated, may wander

-May become agitated in response to external stimuli

-No orientation to person, place or time

-Severely impaired short term memory

-Uses objects inappropriately

-May be able to complete familiar tasks with structure and cuing

-Cannot learn new tasks

-Activity often random with no direction.

-No ability to problem solve or monitor own behavior

-May be able to converse socially for brief periods of time with structure

1. Pays attention for a few minutes at a time

2. Confused, difficulty making sense of anything beyond self

3. Disoriented

4. Needs step by step instructions to complete simple, everyday tasks

5. May become restless when overwhelmed or when too many people are around

6. Poor short term memory
-May remember events prior to injury better than daily routine
-May try to fill in gaps in memory by making things up
-May become frustrated as elements of memory start to return

7. May get stuck on a thought or activity and may need assistance transitioning to the next activity or step

8. Continues to focus on basic needs

-Active or active assistive range of motion

-Simple reaching and single step fine motor tasks

-Simple cognitive activities including orientation to self, place, locating own room, etc.

-Basic hygiene, grooming and dressing tasks with step by step cues

-Adaptations for safety, such as a bed alarm

Demonstration of Level V
VI – Confused, Appropriate

 

 

Moderate Assistance -Sometimes oriented to person, place and time

Long term memory more complete than short term memory

-Able to pay attention to familiar activities for up to 30 minutes with some cueing

-Able to follow simple directions

-Beginning to respond appropriately to family and friends

-Able to complete familiar activities with supervision

-Requires maximum assistance for new activities

-Moderate assistance to problem solve during tasks

-Vaguely recognizes staff members

-Unaware of impairments, safety risk

1. Some confusion due to memory problems.
-may remember main events or main points, but will forget the details

2. Ability to follow a schedule with assistance-may become confused by changes in routine

3. Orientation to month and year

4. Attend to task for about 30 minutes.
-may be distracted by noisy environments
-may be confused by tasks with too many steps

5. Will complete basic self care tasks with help
-will be aware of need to use the toilet

6. May be impulsive, do or say things without thinking first

7. Will be aware of hospitalization due to injury but may not have insight into existing problems
-will be more aware of physical problems than cognitive problems
-may associate problems with being in the hospital and may have the expectation that problems will go away upon return home

8. Able to make sense when speaking

-Therapeutic exercise and activity as appropriate for physical condition with direct supervision and cuing

-Cognitive activities including short term memory exercises, simple sequencing, structured single step problem solving

-Basic hygiene, grooming and dressing tasks with supervision and periodic cues

-Simple cold food preparation

-Simple, familiar housekeeping tasks

-Adaptations to immediate surroundings, including labels on drawers and closets for clothing and personal items

Demonstration of Level VI
VII – Automatic, Appropriate

 

Minimal Assistance for Daily Living Skills -Consistently oriented to person and place in familiar settings; moderate assistance to orient to time

-Minimal supervision/assistance to complete familiar tasks, including self care and household tasks

-Requires minimal supervision for new learning and able to carry over new learning

-Poor recall of recent activities

-Superficial awareness of condition, overestimates abilities, plans for future unrealistic

-Unable to determine the consequences of actions

-Oppositional or uncooperative

-Unaware of the needs of others; unable to recognize inappropriate social interactions

1. Will be able to follow a schedule.

2. Will complete basic self care tasks independently

3. May have problems in new situations

4. May have problems planning, initiating, and completing activities

5. May have trouble paying attention in noisy, crowded settings or stressful situations, such as sporting events or family gatherings
-may demonstrate slower processing speed in stressful situations

6. May not be aware of how changes in memory and cognitive skills affect the future
-may expect to return to previous job or roles

7. Will demonstrate impaired safety awareness and judgment

8. May be inflexible, rigid in thinking, stubborn

9. May express interest in completing an activity, but may require assistance actually completing it

-Therapeutic exercise and activity as appropriate for physical condition with initial instruction and general in-clinic supervision

Cognitive activities including short term memory exercises, simple problem solving, decision making, basic executive function tasks

-Hygiene, grooming and dressing tasks with set-up and periodic supervision

-Simple cooking tasks with assistance and direct supervision, instruction in use of microwave oven, toaster

-Basic housekeeping tasks

-Basic home maintenance or tool use

-Adaptations including labels on kitchen cupboards, closets

Demonstration of Level VII
VIII – Purposeful, Appropriate

 

Stand-By Assistance -Consistently oriented to person, place and time

-Independently attends to and completes tasks in spite of distractions

-Long term and short term memory intact

-May use memory devices to recall “to-do” lists or important events

-Able to initiate and carry out familiar daily routines with stand-by assistance, may need minimal assistance to adapt to changes

-Able to independently complete new tasks once learned

-Aware of and acknowledges impairments, may need stand-by assistance to adapt or correct actions

-May be depressed, irritable, argumentative, or self-centered

-Over or underestimates abilities, may be overly dependent or may refuse help

-Able to recognize inappropriate social interaction and correct it with minimal assistance

1. Will realize that there is a problem with memory and cognitive skills

2. Will start to be more flexible and less rigid in thinking

3. Will begin to compensate for problems

4. Will be able to learn new information at a slower rate

5. May be ready to resume driving or undergo a return to work evaluation

6. Continues to display difficulty dealing with stressful situations

7. Will display poor judgment in new situations and may require assistance

8. May need guidance when making decisions

9. Cognitive problems may not be obvious to people who do not know the person

-Therapeutic exercise and activity as appropriate for physical condition

-Home exercise program with repeated instruction in clinic and supervision in follow through from staff or a family member

-Higher level cognitive activities including problem solving, decision making, judgment, executive function

-Hygiene, grooming, dressing tasks completed independently, monitor for thoroughness

-Housekeeping tasks and food preparation with set-up help, supervision, cuing to problem solve

-Instruction in the use of memory aids including calendars, planners, pill organizers, timers, and other devices

-Instruction and practice in energy conservation and work simplification techniques

Demonstration of Level VIII
IX – Purposeful, Appropriate

 

 

Stand-by Assistance on Request Attends to task, shifts between tasks with no assistance for at least 2 consecutive hours

-Initiates and carries out all familiar routines, may request assistance

-May use memory aids to recall daily schedule, “to-do” list, or important events

-Able to determine the consequences of actions with assistance

-Able to accurately estimate abilities but may need stand-by assistance to adjust to tasks

Able to acknowledge the needs of others and self monitor social interaction with stand-by assistance

-May be depressed or irritable; low frustration tolerance

1. Will be able to pay attention for long, sustained periods of time.

2. Aware of limitations
-may need some assistance to problem solve during tasks
-may become depressed or have low frustration tolerance

3. Will complete all familiar tasks
-may ask for help problem solving

4. Will compensate for memory loss by using memory aids

5. Will consider the point of view of others during conversation

6. May return to work or daily routine with some assistance

-Therapeutic exercise and activity as appropriate for physical condition

-Home exercise program, may complete independently after repeat in-clinic instruction

-Able to complete hygiene, grooming and dressing tasks independently

-Housekeeping and food preparation tasks with supervision, assist with problem solving as needed

-Continued instruction in the use of memory aids

-Instruction and assistance with higher level instrumental activities of daily living (IADLs), including money management, taking medications, making and keeping appointments

-Assessment to determine potential to resume driving

-Instruction in relaxation techniques

Demonstration of Level IX
X – Purposeful, Appropriate

 

Modified Independent Independently carries out daily routine, may need extra time or more adaptive strategies than usual

-Able to multi-task, may need periodic breaks

-Able to obtain or create own memory aids

-Able to determine the consequences of actions but may need extra time or adaptive strategies to solve problems and make decision

-Recognizes and appropriately responds to the feelings of others

-Social interaction consistently appropriate

-May become irritable or have low frustration tolerance when sick, tired or frustrated; may have periodic episodes of depression

1. Will complete all daily activities with adaptations or extra time

2. May need rest breaks

3. Will compensate for memory loss, using adaptive aids or methods

4. Will problem solve and make decisions with extra time or adaptations

5. May become depressed or display low frustration tolerance when sick or tired

6. Will return to work or daily routine with adaptations

-Home exercise and activity programs with follow up monitoring

-Instruct in use of and monitor follow through with memory aids, including calendars, pill boxes, alarms and timers, assistive technology

-Follow up checks to insure independence with housekeeping, food preparation, safety at home

-Periodic monitoring of medications, money management, appointments

-Driving instruction to regain drivers license if appropriate

Demonstration of Level X

 

Link between Allen Cognitive Levels & Rancho Los Amigos Scale 

For more detailed information re-Allen Cognitive Levels, refer to Module 6 https://passtheot.com/allen-cognitive-levels/
ACL Allen Cognitive Levels  RLAS Rancho Los Amigos
ACL 0 Coma 1    No Response 

Total Assistance

Patient does not respond to external stimuli.
– No observable change in behavior when presented with any kind of stimuli.
0.8 Generalized reflexive actions 2    Generalized Response

Total Assistance

Patient reacts to external stimuli in nonspecific, inconsistent, and non-purposeful manner with stereotypic and limited responses.
ACL 1

Total Assistance

Automatic Actions

Automatic motor responses. Behavior is mostly reflexive
Minimal awareness of and reaction to the external environment
• Arousal and response elicited for only a few seconds at a time

1.0 Withdraws from noxious stimulus 3    Localized Response

Total Assistance

Patient responds specifically but inconsistently to stimuli and may follow simple commands for motor actions.
Reacts to pain by withdrawing or moaning. Blinks at strong light and follows moving objects. Turns toward sound. May respond to simple commands, to family or friends but not other people. 
1.2 Responds to stimuli with one sensory system
1.4 Locates stimuli
1.6 Rolls in bed
1.8 Raises body parts
ACL 2

Max Assistance

Postural Actions

Can overcome the effects of gravity
• Can imitate gross motor actions
There is a lack of awareness of the effects that actions have on objects or other people
Maximum assistance with all activities
May assist caregiver with simple tasks – can assist with hygiene and dressing, and feed self with finger food
• ADLs can be accomplished by imitation
Safety risk for wandering

2.0 Overcomes gravity/sits 4   Confused/Agitated

Max Assistance

Patient exhibits bizarre, non-purposeful, incoherent, inappropriate behaviors. Has no short-term recall and attention is short and nonselective. Completes simple, routine tasks with assistance. Overly focused on basic needs, such as eating, going to the bathroom, etc. Has difficulty following directions. Does not understand feelings or what is happening in surroundings.
– Heightened state of activity, may move constantly, movements not purposeful. May run away or become aggressive. Responds to stimuli by acting out– hitting, yelling or screaming, using abusive language, extreme behavior due to confusion, may need restraints to avoid self-injury
2.2 Righting reactions/stands
2.4 Aimless walking
2.6 Directed walking
2.8 Uses grab bars
ACL 3

Mod Assistance

Manual Actions

Uses hands to manipulate objects. 
• Responds to tactile cues to perform manual actions
Emergence of cause and effect, but actions are disorganized
Performs familiar ADL tasks (e.g. basic grooming) independently with some reminders
• Attention span is short (maximum 30 minutes). Easily distracted by environmental stimuli

3.0 Grasps objects 5   Confused, Inappropriate Non-Agitated

Max Assistance

Alert, not agitated, may wander. No orientation to person, place or time. Absent goal directed, problem solving, self-monitoring behavior. Continues to focus on basic needs. May be able to complete familiar tasks with structure and cuing- needs step by step instructions to complete simple, everyday tasks. Uses objects inappropriately. Consistently follows simple commands. New information is not retained.
-Activity often random with no direction. Cannot learn new tasks. No ability to problem solve or monitor own behavior
3.2 Distinguishes objects
3.4 Sustains actions on objects
3.6 Notes effects on objects
3.8 Uses all objects
ACL 4

Min Assistance

Goal Directed Actions

Big step for independence
Activities are purposeful and able to perform short tasks
Minimal assistance with familiar, goal directed activities
May be able to carry out established routines- basic ADLs are intact, may ask for assistance
Unable to cope with unexpected events or changes in routine
Difficulty learning new tasks and generalizing skills.
• Relies heavily on visual cues. Requires visual demonstrations for tasks because cannot follow verbal and written directions
Needs assistance with new tasks, for anticipating needs

4.0 Sequences familiar actions 6   Confused, Appropriate

Moderate Assistance

Patient demonstrates carry-over for relearned familiar tasks (e.g. self-care) but not for new tasks. Able to follow simple directions. Able to complete familiar activities with supervision. Requires assistance for new activities. Moderate assistance to problem solve during tasks. Able to pay attention to familiar activities for up to 30 minutes with some cueing. Unaware of impairments, safety risk. 
– Able to complete familiar activities with supervision. Able to follow a schedule with assistance- may become confused by changes in routine.
4.2 Differentiates features of objects
4.4 Completes familiar goal
4.6 Personalizes features of objects
4.8 Learns by rote memorization
ACL 5

Standby Assistance/Supervision 

Exploratory Actions

New learning can occur and can generalize skills
Can learn independently through exploratory actions and trial and error
• Participates well in concrete tasks 
• Able to alter actions through trial and error
Poor organization, planning and socialization

5.0 Comparing and changing variations in actions and objects 7    Automatic, Appropriate

Minimal Assistance for Daily Living Skills

Patient performs daily routines automatically, and shows carry-over for new learning. Will be able to follow a schedule. Will demonstrate impaired safety awareness and judgment. May express interest in completing an activity, but may require assistance actually completing it. 
– Minimal assistance to complete familiar tasks, including self-care and household tasks. Requires minimal supervision for new learning and able to carry over new learning. May have problems planning, initiating, and completing activities.
5.2 Discriminates parts of activity
5.4 Self-directed learning 8    Purposeful, Appropriate

Stand-By Assistance

Patient oriented and responds to the environment but abstract reasoning abilities are decreased relative to premorbid levels. Able to independently complete new tasks once learned. Independently attends to and completes tasks in spite of distractions.
5.6 Considers social standards 9    Purposeful, Appropriate

Stand-By Assistance- on request

Patient able to shift between tasks. Aware of limitations. Able to acknowledge the needs of others and self-monitor social interaction with stand-by assistance. Will consider the point of view of others during conversation.
5.8 Consulting with others
ACL 6

Modified- Complete independence

Planned Actions

No global cognitive impairment
Independent with all activities
• New motor learning can be done safely and consistently.
• Hazardous situations are anticipated and avoided, or help is sought when needed.
• Mobility, communications, and maintenance of adaptive equipment is self-monitored.
• Able to think of hypothetical situations and plan ahead to prevent mistakes
• Able to consider the consequences of actions
• Able to follow multi step verbal or written cues

6.0 Typically functioning adult brain and functional cognitive capacities 10   Purposeful, Appropriate

Modified Independent

Patient independently carries out daily routine, may need extra time/adaptive strategies. Will compensate for memory loss by using adaptive aids or methods. Able to obtain or create own memory aids. Able to multi-task, may need periodic breaks

Comparing the Allen Scale of Cognitive Levels and Modes with Other Global Measures of Function- Catherine A. Earhart BA, OT Cert., OTR/L and Claudia K. Allen, MA, FAOTA, OT
https://allencognitive.com/wp-content/uploads/Ed-Corner-Comparing-Allen-Scale-with-other-Global-Measures-of-Function.pdf