Rancho Los Amigos Level of Cognitive Functioning Scale

Original Editor - Venugopal Pawar

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Introduction

The Rancho Los Amigos Scale (RLAS), also known as the Ranchos Scale describes the cognitive and behavioral patterns found in brain injury patients as they recover from injury. It was originally developed by the head injury team at the Rancho Los Amigos Hospital in Downey, California to assess patients emerging from a coma. The original scale consisted of eight levels and later on, was revised and is known as the Rancho Los Amigos Revised Scale (RLAS-R). [1] The scale was developed based on assumption that observation of the type, nature, and quality of the patient’s behavioral responses can be used to estimate the cognitive level at which the patient is functioning. [2]

The RLAS originally had 8 levels, while the revision added levels 9 and 10 to better reflect the highest levels of recovery. The original levels and the revised levels of the RLAS-R levels were dichotomized into two categories:

  • Inferior functioning (RLAS-R 1–8) and
  • Superior functioning (RLAS-R 9-10) [3]

Objective

  • Used to understand a brain injury patient's abilities, impairments, and prognosis better, as they move through the stages of recovery
  • Facilitates communication among treating healthcare professionals and aids in treatment planning [2][3]

Intended Population

  • Brain Injury [2]

Method of Use [1][2]

In the Ranchos Los Amigos Scale, each level is presented as a behavioral description in narrative form and the rater must decide which level best describes the patient’s present behaviors. Different levels are given below:

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.[2]
  • Concurrent validity with the Stover Zeiger scale was 0.92[2]
  • Predictive validity from admission to discharge 0.57 to 0.68[2]

Links

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

References

  1. 1.0 1.1 Lin K, Dulebohn SC. Ranchos Los Amigos. Available from : https://www.ncbi.nlm.nih.gov/books/NBK448151/
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Flannery J, Abraham I. Psychometric properties of a cognitive functioning scale for patients with traumatic brain injury. Western journal of nursing research. 1993 Aug;15(4):465-82. available from: https://journals.sagepub.com/doi/10.1177/019394599301500406
  3. 3.0 3.1 Stenberg M, Godbolt AK, Nygren De Boussard C, Levi R, Stålnacke BM. Cognitive impairment after severe traumatic brain injury, clinical course and impact on outcome: a Swedish-Icelandic study. Behavioural neurology. 2015;2015. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689900/#B30