The concept of rehabilitation beginning at the time of injury and continuing through
definitive care into the rehabilitation phase has been adopted by the trauma center system. Rehabilitation must
be started as early as possible to allow the patient the maximum possible recovery.1 An assessment tool was needed to objectively rate the level of cognitive functioning,
guiding the rehabilitation team in their plan of care, especially during this early treatment period.1 The Rancho Los Amigos Levels of Cognitive
Functioning, or simply the Rancho Scale, was developed to fill this need by studying the recovery pattern of traumatic
head injured patients.2
The Rancho Scale (see figure 1) rates the level of cognitive functioning on a scale of 1-8. The range of behaviors
is from unresponsive in Rancho 1, to alert, oriented, with purposeful and appropriate responses at Rancho 8.2
Level 1
No response: Patient appears to be in a deep sleep and is completely unresponsive
to any stimuli.
Level 2
Generalized response: Patient reacts inconsistently and nonpurposefully to stimuli
in a nonspecific manner. Responses are limited and are often the same regardless of stimulus presented. Responses
may be physiologic changes, gross body movements, and/or vocalization.
Level 3
Localized response: Patient reacts specifically but inconsistently to stimuli. Responses
are directly related to the type of stimulus presented. Patient may follow simple commands such as "close
eyes", or "squeeze hand" in an inconsistent. delayed manner.
Level 4
Confused and agitated response: Patient acts bizarre and nonpurposeful in relation
to his or her immediate environment. Patient does not discriminate among persons or objects and is unable, to cooperate
directly with treatment efforts. Vocalization is frequently incoherent or lnappropriate to the environment, and
the patient may confabulate. Gross attention to the environment is very short. and the patient often has no selective
attention. Patient lacks short-term recall.
Level 5
Confused, inappropriate. and nonagitated response: Patient is able to respond to
simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure,
responses are nonpurposeful, random, or fragmented. Patient pays gross attention to the environment but is highly
distractible and lacks ability to focus attention on a specific task. With structure, patient may be able to converse
on a social-automatic level for short periods of time, but vocalization is often inappropriate and confabulatory.
Memory is severely impaired and patient often shows inappropriate use of objects. Patient may perform a previousIy
learned task with structure but is unable to learn new information.
Level 6
Confused and appropriate response: Patient shows goal directed behavior but is dependent
on external input for direction. Patient follows simple directions consistently and carries over information for
relearned tasks but usually not for new tasks. Responses may be incorrect because of memory problems but appropriate
to the situation. Past memories show more depth and detall than recent memory.
Level 7
Automatic and appropriate response: Patient shows appropriate behavior and appears,
oriented within hospital and home settings and goes through daily routine automatically but is frequently robotlike,
with minimal-to-absent confusion, and has shallow recall of actIvities. Patient carries over information for new
learning but at a decreased rate. With structure, patient is able to initiate social or recreational activities.
Judgment remains impaired.
Level 8
Purposeful and appropriate response: Patient is able to recall and integrate past
and recent events and is aware of and responsive to environment. Patient carries over information for new learning
and needs no supervision once activities are learned. Patient may continue to show decreased ability, relative
to premorbid abilities, in abstract reasoning, tolerance to stress, and judgment in emergencies or unusual circumstances.
Figure 5. The Rancho Los Amigos Levels of Cognitive Functioning.2
The rehabilitation team, consisting of Speech Pathologists, Occupational Therapists,
and Physical Therapists will use the Rancho rating to guide their plan of care. By focusing on only the behaviors
the patient is capable of at a given time, the team maximizes the benefit of the therapy given and uses the available
resources most efficiently and effectively.2
When using the Rancho Scale it must be kept in mind that the level of the patients functioning will vary with fatigue,
stimulation, and the familarity and predictability of the patients enviroment. As a result, and also because progress
occurs slowly and in small steps, not all patients will fit strictly into one of the eight levels. When this occurs
it is suggested to record the appropriate levels together. An example of this would be recording a Rancho 3-4.2
REFERENCES
Cowley, R. (1982). Shock Trauma Critical Care Manual. Baltimore: University Press.
Hagen, C. (1981). Language Disorders Secondary to Closed Head Injury: Diagnosis
and Treatment. Language Disorders, 1, 73-87.
