Rancho Los Amigos Scale - Levels of Cognitive Functioning

Level I
No Response: Total Assistance

• Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli.

Level II
Generalized Response: Total Assistance

• Demonstrates generalized reflex response to painful stimuli.
• Responds to repeated auditory stimuli with increased or decreased activity.
• Responds to external stimuli with physiological changes generalized, gross body movement, and/or not purposeful vocalization.
• Responses noted above may be the same regardless of type and location of stimulation.
• Responses may be significantly delayed.

Level III
Localized Response: Total Assistance

• Demonstrates withdrawal or vocalization to painful stimuli.
• Turns toward or away from auditory stimuli.
• Blinks when strong light crosses visual field.
• Follows moving object passed within visual field.
• Responds to discomfort by pulling tubes or restraints.
• Responds inconsistently to simple commands.
• Responses directly related to type of stimulus.
• May respond to some persons (especially family and friends) but not to others.

Level IV
Confused/Agitated: Maximal Assistance

• Alert and in heightened state of activity.
• Purposeful attempts to remove restraints or tubes or crawl out of bed.
• May perform motor activities such as sitting, reaching, and walking, but without any apparent purpose or upon another's request.
• Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
• Absent short-term memory.
• May cry out or scream out of proportion to stimulus even after its removal.
• May exhibit aggressive or flight behavior.
• Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
• Unable to cooperate with treatment efforts.
• Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V
Confused, Inappropriate Non-agitated: Maximal Assistance

• Alert, not agitated, but may wander randomly or with a vague intention of going home.
• May become agitated in response to external stimulation and/or lack of environmental structure.
• Not oriented to person, place, or time.
• Frequent brief periods, non-purposeful sustained attention.
• Severely impaired recent memory with confusion of past and present in reaction to ongoing activity.
• Absent goal-directed, problem-solving, self-monitoring behavior.
• Often demonstrates inappropriate use of objects without external direction.
• May be able to perform previously learned tasks when structured and cues provided.
• Unable to learn new information.
• Able to respond appropriately to simple commands fairly consistently with external structures and cues.
• Responses to simple commands without external structure are random and non-purposeful in relation to command.
• Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
• Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI
Confused, Appropriate: Moderate Assistance

• Inconsistently oriented to person, time, and place.
• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
• Remote memory has more depth and detail than recent memory.
• Vague recognition of some staff.
• Able to use assistive memory aide with maximum assistance.
• Emerging awareness of appropriate response to self, family, and basic needs.
• Moderate assist to problem solve barriers to task completion.
• Supervised for old learning (e.g., self care).
• Shows carry over for relearned familiar tasks (e.g., self care).
• Maximum assistance for new learning with little or no carry over.
• Unaware of impairments, disabilities, and safety risks.
• Consistently follows simple directions.
• Verbal expressions are appropriate in highly familiar and structured situations.

Level VII
Automatic, Appropriate: Minimal Assistance for Daily Living 

• Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time.
• Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.
• Minimal supervision for new learning.
• Demonstrates carry over of new learning.
• Initiates and carries out steps to complete familiar personal and household routine, but has shallow recall of what he/she has been doing.
• Able to monitor accuracy and completeness of each step in routine personal and household ADL's and modify plan with minimal assistance.
• Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately, and completely carry out his/her household, community, work ,and leisure ADL's.
• Minimal supervision for safety in routine home and community activities.
• Unrealistic planning for the future.
• Unable to think about consequences of a decision or action.
• Overestimates abilities.
• Unaware of others needs and feelings.
• Oppositional/uncooperative.
• Unable to recognize inappropriate social interaction behavior.