The Rancho Los Amigo scale was developed by a California hospital to help provide a means of determining various levels of recovery following a head injury. Although it is sometimes difficult to determine the exact stage of an individual, this scale is a convenient guideline.
RANCHO LOS AMIGOS HOSPITAL:
SCALE OF COGNITIVE FUNCTIONING
Person unresponsive to stimuli.
II. GENERALIZED RESPONSE
Person reacts inconsistently and nonpurposefully to stimuli. Responses are limited and often delayed.
III. LOCALIZED RESPONSE
Person reacts specifically but inconsistently to stimuli. Responses are related to type of stimulus presented, such as focusing on an object visually or responding to sounds.
IV. CONFUSED, AGITATED
Person is extremely agitated and in a high state of confusion. Shows non-purposeful and aggressive behavior. Unable to fully cooperate with his treatments due to short attention span. Maximal assistance with self-care skills is needed.
V. CONFUSED, INAPPROPRIATE, NON-AGITATED
Person is alert and can respond to simple commands on a more consistent basis. Highly distractible and needs constant cueing to attend to an activity. Memory is impaired with confusion regarding past and present. The person can perform self-care activities with assistance. May wander and need to be watched carefully.
VI. CONFUSED, APPROPRIATE
Person shows goal directed behavior, but still needs direction from staff. Follows simple tasks consistently and shows carryover for relearned tasks. The person is more aware of his/her deficits and has increased awareness of self, family and basic needs.
VII. AUTOMATIC APPROPRIATE
Person appears oriented in home and hospital and goes through daily routine automatically. Shows carryover for new learning but still requires structure and supervision to ensure safety and good judgment. Able to initiate tasks in which he has an interest.
VIII. PURPOSEFUL APPROPRIATE
Person is totally alert, oriented, and shows good recall of past and recent events. Independent in the home and in the community. Shows a decreased ability in certain areas but has learned to compensate.
Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.
Suggestions for the Family during these periods:
Levels I and II:
1. Talk to your loved one in normal conversational tones about familiar things. If this seems awkward to you, remember your relative may be hearing more than you realize. Play your loved one's favorite music or taped messages from family members, and friends.
2. Let us know the interests of your loved one. Many times, they will respond best to familiar things like a favorite song or television show.
3. This will be the hardest time for you and other family members. Often what you do will appear to have no effect. This stage can go on for several months, without apparent changes.
4. Provide stimulation for 10-15 minute intervals; do not expect response to all stimulation.
Level III:
1. Be alert to changes in your family member's reaction to you. Since some
persons respond best to familiar voices, you may notice increased responsiveness from your relative first. Please let other members of the team know about changes you see immediately.2. Talk to the
person in a normal conversational tone.3. Use only simple one-step directions. Example: "Squeeze my hand:'
4. Give the
person ample time to respond before repeating instructions.5. Do not continually question your relative to see "how they are doing:' You will probably confuse them, since they are usually unable to recall recent events.
6. Provide your loved one with frequent orientation to the day of the week, the place, and the reason that they are in the hospital, because they will not remember your earlier explanation. A large calendar placed within the
persons view with each day crossed off may prove helpful.7. Allow the
person adequate rest time. While it is natural to want to spend most of the time you are with them talking and attempting to do things, it is more beneficial to intersperse this with rest periods.8. Frequently reassure your loved one that their needs are being met and that they are safe.
Level IV:
1. Provide a calm, soothing, relaxed atmosphere when you visit with your family member. If you find yourself getting upset or angry, go out and come back in when you regain your composure.
2. Use short, simple directions and repeat them frequently.
3. Simplify your vocabulary and slow down your rate of speech.
4. Don't expect the person to remember recent events or instructions. Tell the person things that you want known. Avoid questioning the person, since this is likely to heighten irritability.
5. Provide orientation information frequently (date, hospital, city, and cause of hospitalization) and correct the person gently. Don't argue with the person or criticize them for forgetfulness.
6. If restraints are being used, please leave them on the person. They are present because the staff is concerned about the persons security and safety during this period of disorientation and agitation. At our hospital, restraints are used only when absolutely necessary to protect the person from injuring him/herself.
Level V:
1. Provide cues which will enable the person to automatically give the correct answer to your questions about past or current events.Example: "After your graduated from high school, didn't you leave Erie?", rather than "Where did you live in 19837".
2. Supply fewer reminders for completing steps than during Level IV. They should remember and keep to an activity for 2-3 minutes before they need reminders.
3. Continue to use simple vocabulary and shod, simple directions, but try not to treat the
person in a childish manner.4. Correct inaccurate statements gently.
5. Give the
person brief rest periods, change the topic, or calmly suggest that the person relax if they become upset.6. Avoid open-ended questions. Do not "quiz" the
person regarding orientation. Provide the information.Level VI:
1. Use normal conversation with the person, but continue to be specific. The person will still not understand involved jokes or sarcasm.2. Expect the person to work with you on tasks for approximately 10-15 minutes.
3. You may not need to provide clues in order to encourage the person to answer questions about their past, their treatment schedule, or particularly important events that occurred that day.
4. Assist the person by helping to write their daily activities in their daily journal (log). It may be beneficial to go over the course of the day with your loved one.
5. Continue to encourage the person to participate in the entire program. Since the person usually does not acknowledge their limitations resulting from the injury, they may begin to refuse to attend therapies. You can help immensely to keep them motivated.
Level VII:
1. Strongly support the need for continued treatment directed at thinking skills and compensation for memory. A person is apt to claim they are completely normal, and that they want to return home and resume their normal activities. Although they may "feel" that they have no remaining problems, they are actually incorrect.2. Check with the attending physician or Nursing staff regarding any necessary restrictions on the person's driving, drinking, etc., or other activities while they are home on pass. This is important, because the person's own assessment of their abilities is frequently not accurate.
3. Frequently discuss daily activities with the person to assist in expanding their memory. Encourage them to remember as much detail as possible about things they have done and conversations they have had. Make sure they record events in their journal (log) if they are using one.
4. Help the person fill in gaps in their memory for events immediately prior to the accident. Some people will have permanent memory losses for this time.
5. Talk with the person in a normal fashion. There should be no need to use simple sentences or words. However, remember that the person will not catch "subtle humor" and is apt to interpret words very literally. These difficulties can lead the person to misunderstand the real meaning of what is being said to them. Therefore, you should be very explicit regarding what you say to the person.
Level VIII:
1. Participate with the person in familiar activities so that you can help them become aware of minor limitations in their thinking and problem solving. Notice changes in how well they do on a particular task, and talk about these changes with them in a non-critical way. Point out alternative ways to accomplish goals. Use non-critical, non-competitive approaches.2. Encourage the
person to use note taking as a way to get around any remaining memory problems. Since almost all head injured people (even at Level VIII) still have problems freely recalling new facts, your loved one may need to develop life-long habits of writing down important facts, instructions, and things they need to do. Developing this habit is vitally important to the future of the person. They may feel somewhat embarrassed about doing this, and feel that it is not necessary. It is important to help them understand that although they have made much progress, remaining memory problems are not apt to go away, and they must learn ways to get around them.3. Discuss with the person what kinds of situations make them angry, and what they can do in these situations. Although their tolerance for frustration is much better by this stage, they will still come across certain situations which frustrate them more easily and make them angry. Help the person begin to discover what these situations are. Then talk with them about how they can either learn to avoid these situations as much as possible, or learn new ways of behaving in those situations.
4. Encourage the person to talk to you about feelings of depression or nervousness about returning home. Assure them that these feelings are normal, and that they will improve as they have more practice with living outside of the hospital. Do not try to talk the person out of these feelings, and avoid telling them that they have no reason to feel that way. Freely talk about what may be community reactions to the person upon returning home, especially if physical disabilities are evident.
5. Maintain a hopeful, yet realistic, attitude toward the person's future. Learning to cope with a head injury and with the possible permanent and cognitive limitations takes months, at a minimum. Even after discharge, feel free to contact any member of the treatment team if questions or problems arise.