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Rancho Los Amigos Scale of Cognitive Functioning
From the Head Trauma Research Project
New York University Medical Center Institute of Rehabilitation Medicine

Physicians discharge patients from intensive care units (ICU) once their vital signs are stable for a period of time and they are no longer at risk of acute medical and surgical problems, such as bleeding or rapidly increasing intracranial pressure.

Some hospitals have special units for patients with various neurologic problems. Others offer acute brain injury rehabilitation programs. These programs are designed to assess the physical, cognitive, and behavioral status of patients, establish specific treatment, and prevent complications. Rehabilitation staff members consider each patient's potential carefully and devise individual plans.

Family members and friends know that discharge from the ICU is a step forward. They are relieved that the patient's condition has stabilized to the point where he or she no longer needs intense observation. Still, they may feel anxious about leaving the security of the ICU. They have come to know and trust the ICU staff and now must get acquainted with a whole new group of caregivers. It is reassuring to know that the staff is aware of these feelings and is available to help patients and families become accustomed to a new unit.

Many patients are in a semi-comatose or confused and restless state when they are discharged from the ICU. Assessing their physical problems may not be difficult, but cognitive and behavioral deficits are harder to pinpoint. To evaluate these aspects, the Rancho Los Amigos Scale of Cognitive Functioning, (RLA) named for the center where it was developed, is used in acute rehabilitation settings throughout the country.

The following is a brief description of the Rancho Los Amigos Scale of Cognitive Functioning:

Level 1 - No response. The patient appears to be in a very deep sleep or coma and does not respond to voices, sounds, light, or touch.

Level 2 - Generalized response. The patient moves around, but movement does not seem to have a purpose or consistency. Patients may open their eyes but do not seem to focus on anything in particular.

Level 3 - Localized response. Patients begin to move their eyes and look at specific people and objects. They turn their heads in the direction of loud voices or noise. Patients at level 3 may follow a simple command, such as "Squeeze my hand."

Level 4 - Confused and agitated. The patient is very confused and agitated about where he or she is and what is happening in the surroundings. At the slightest provocation, the patient may become very restless, aggressive, or verbally abusive. The patient may enter into incoherent conversation.

Level 5 - Confused, inappropriate but not agitated. The patient is confused and does not make sense in conversations but may be able to follow simple directions. Stressful situations may provoke some upset, but agitation is no longer a major problem. Patients may experience some frustration as elements of memory return.

Level 6 - Confused but appropriate. The patient's speech makes sense, and he or she is able to do simple things such as dressing, eating, and teeth brushing. Although patients know how to perform a specific activity, they need help discerning when to start and stop. Learning new things may also be difficult.

Level 7 - Automatic, appropriate. Patients can perform all self-care activities and are usually coherent. They have difficulty remembering recent events and discussions. Rational judgments, calculations, and solving multi-step problems present difficulties, yet patients may not seem to realize this.

Level 8 - Purposeful and appropriate. At this level, patients are independent and can process new information. They remember distant and recent events and can figure out complex and simple problems.

As patients improve after a brain injury, they may move from one level to the next, but often demonstrate characteristics of more than one level at a time. Depending on the extent and type of injury, they may remain at any one level for an extended period. Using information from this scale, the health care team can begin treatment that will help develop skills and promote appropriate behavior. Health care professionals often suggest the following simple measures to family and friends while the patient is still in a coma: Always talk as if the patient hears you when you are nearby.

Speak directly to the patient abut simple things and reassure him or her frequently.

Explain events and noises in the surrounding area.

Tell the patient what has happened and where he or she is.

Touch and stroke the patient gently.

Tell the patient who you are each time you approach the bedside.

Hold his or her hand.

Play the patient's favorite music or tape a soothing message that can be played when you are away from the bedside.

For parents of young children, tape yourself singing or reading your child's favorite stories.

Glasgow Coma Scale
Instructions for Scoring the Glasgow Coma Scale
From the Head Trauma Research Project New York University Medical Center
Institute of Rehabilitation Medicine
Explanation of the Glasgow Coma Scale for the layman

Once the patient is partially stabilized in the emergency department of the hospital, he or she is usually transferred to an intensive care unit where assessment and treatment continue. Physicians commonly use a standardized test, the Glasgow Coma Scale, to evaluate brain injuries.

It rates three categories of patient responses; eye opening, best verbal response, and best motor response. Levels of responses indicate the degree of nervous system or brain impairment. Eye opening tests indicate the function of the brain's activating centers.

The patient's eyes may open spontaneously, only on verbal request, or only with painful stimulation. Best verbal response indicates the condition of the central nervous system within the cerebral cortex. The patient may be able to speak normally and be oriented to time and place, or he or she may be disoriented and use inappropriate words.

At the other end of the scale, the patient may only make incomprehensible sounds or no sound at all.

Best motor response tests examine a patient's ability to move arms and legs. Responses may vary from the ability to move about on command to the ability to move only in response to pain.

Each element of the Glasgow Coma Scale is rated using "1" as the lowest possible score in each category. Physicians classify brain injuries as mild, moderate, or severe, using these scores. The

Glasgow Score is obtained by adding the eye opening, verbal response, and motor response scores.

Eye Opening Response E Score Characteristics

None 1 Eyes always closed; not attributable to ocular swelling
To pain 2 Eyes open in response to painful stimulus
To speech 3 Eyes open in response to speech or shout; does not imply patient obeys command to open eyes
Spontaneous 4 Eyes open; does not imply intact awareness

Best Motor Response
(stimuli: pressure on nail bed and suprorbital pressure)

Response M Score Characteristics
No Response 1
No motor response to pain
Extension 2 Extension at elbow
Abnormal flexion 3 Includes preceding extension, stereotyped flexion posture, extreme wrist flexion, abduction of upper arm, flexion of fingers over thumb: see administration instruction; if unsure, score as withdrawal
Withdrawal 4 Normal flexor withdrawal; no localizing attempt to remove stimulus
Localizes pain 5 Attempt made to remove stimulus, e.g., hand moves above chin toward supraocular stimulus Obeys commands 6 Follows simple commands

Best Verbal Response

Response V Score Characteristics
No Response 1 No sounds
Incomprehensible 2 Moaning, groaning, grunting; incomprehensible Inappropriate 3 Intelligible words, but not in a meaningful exchange; e.g., shouting, swearing; no meaningful conversation
Confused 4 Responds to questions in conversational manner, but responses indicate varying degrees of disorientation and confusion
Oriented 5 Normal orientation to time, place, person; appropriate conversation

Summed Glasgow Coma Scale Score = E+M+V (3-15)

Comments, additions, and suggestions about this page may be sent to:

The Brain Injury Association Of Connecticut
1800 Silas Deane Highway, Suite 224
Rocky Hill, CT 06067
Phone: (203) 721-8111 or 1-800-278-8242
Fax: (203) 721-9008

The Brain Injury Association of Connecticut does not support, endorse, or recommend any product, method of treatment, or program for persons with head injury. We endeavor to inform and believe that you have the right to know what help is available. Information within these pages consists of items that may be of interest to our community.