Rancho Cognitive Scale - Information

PATIENT INFORMATION
Family Guide to The Rancho
Levels of Cognitive Functioning

Cognition refers to a person's thinking and
memory skills. Cognitive skills include paying
attention, being aware of one's surroundings,
organizing, planning, following through on
decisions, solving problems, judgement,
reasoning, and awareness of problems. Memory
skills include the ability to remember things
before and after the brain injury. Because of the
damage caused by a brain injury, some or all of
these skills will be changed.

The Rancho Levels of Cognitive Functioning is
an evaluation tool used by the rehabilitation team.
The eight levels describe the patterns or stages of
recovery typically seen after a brain injury. This
helps the team understand and focus on the
person's abilities and design an appropriate
treatment program. Each person will progress at
their own rate, depending on the severity of the
brain damage, the location of the injury in the
brain and length of time since the brain injury.
Some individuals will pass through each of the
eight levels, while others may progress to a certain
level and fail to change to the next higher level.

It is important to remember that each person is an
individual and there are many factors that need to
be considered when assigning a level of cognition.
There are a range of abilities within each of the
levels and your family member may exhibit some
or all of the behaviors listed below.

COGNITIVE LEVEL I
NO RESPONSE
A person at this level will:
• not respond to sounds, sights, touch or
movement.

COGNITIVE LEVEL II
GENERALIZED RESPONSE
A person at this level will:
• begin to respond to sounds, sights, touch or
movement;
• respond slowly, inconsistently, or after a delay;
• responds in the same way to what he hears, sees
or feels. Responses may include chewing,
sweating, breathing faster, moaning, moving,
and/or increasing blood pressure.

COGNITIVE LEVEL III
LOCALIZED RESPONSE
A person at this level will:
• be awake on and off during the day;
• make more movements than before;
• react more specifically to what he sees, hears, or
feels. For example, he may turn towards a sound,
withdraw from pain, and attempt to watch a
person move around the room;
• react slowly and inconsistently;
• begin to recognize family and friends;
• follow some simple directions such as "Look at
me" or "squeeze my hand";
• begin to respond inconsistently to simple
questions with "yes" and "no" head nods.
What family/friends can do at Cognitive
Levels I, II, and III
• Explain to the individual what you are about to
do. For example, "I'm going to move your leg."
• Talk in a normal tone of voice.
• Keep comments and questions short and simple.
For example, instead of "Can you turn your head
towards me?", say, "Look at me".
• Tell the person who you are, where he is, why
he is in the hospital, and what day it is.
• Limit the number of visitors to 2-3 people at a
time.
• Keep the room calm and quiet.
• Bring in favorite belongings and pictures of
family members and close friends.
• Allow the person extra time to respond, but
don't expect responses to be correct.
Sometimes the person may not respond at all.
• Give him rest periods. He will tire easily.
• Engage him in familiar activities, such as
listening to his favorite music, talking about
the family and friends, reading out loud to
him, watching TV, combing his hair, putting
on lotion, etc.
• He may understand parts of what you are
saying. Therefore, be careful what you say in
front of the individual.

COGNITIVE LEVEL IV
CONFUSED AND AGITATED
A person at this level may:
• be very confused and frightened;
• not understand what he feels or what is
happening around him;
• overreact to what he sees, hears, or feels by
hitting, screaming, using abusive language, or
thrashing about. This is because of the
confusion;
• be restrained so he doesn't hurt himself;
• be highly focused on his basic needs; ie.,
eating, relieving pain, going back to bed, going
to the bathroom, or going home;
• may not understand that people are trying to
help him;
• not pay attention or be able to concentrate for
a few seconds;
• have difficulty following directions;
• recognize family/friends some of the time;
• with help, be able to do simple routine
activities such as feeding himself, dressing or
talking.

What family/friends can do at Cognitive
Level IV:
• Tell the person where he is and reassure him that
he is safe.
• Bring in family pictures and personal items from
home, to make him feel more comfortable.
• Allow him as much movement as is safe.
• Take him for rides in his wheelchair, with
permission from nursing.
• Experiment to find familiar activities that are
calming to him such as listening to music, eating,
etc.
• Do not force him to do things. Instead, listen to
what he wants to do and follow his lead, within
safety limits.
• Since he often becomes distracted, restless, or
agitated, you may need to give him breaks and
change activities frequently.
• Keep the room quiet and calm. For example,
turn off the TV and radio, don't talk too much
and use a calm voice.
• Limit the number of visitors to 2-3 people at a
time.

COGNITIVE LEVEL V
CONFUSED AND INAPPROPRIATE
A person at this level may:
• be able to pay attention for only a few minutes;
• be confused and have difficulty making sense of
things outside himself;
• not know the date, where he is or why he is in
the hospital;
• not be able to start or complete everyday
activities, such as brushing his teeth, even when
physically able. He may need step-by-step
instructions;
• become overloaded and restless when tired or
when there are too many people around; have a
very poor memory, he will remember past events
from before the accident better than his daily
routine or information he has been told since the
injury;
• try to fill in gaps in memory by making things up;
(confabulation)
• may get stuck on an idea or activity
(perseveration) and need help switching to the
next part of the activity;
• focus on basic needs such as eating, relieving
pain, going back to bed, going to the
bathroom, or going home.

What family/friends can do at Cognitive
Level V.
• Repeat things as needed. Don't assume that he
will remember what you tell him.
• Tell him the day, date, name and location of
the hospital, and why he is in the hospital
when you first arrive and before you leave.
• Keep comments and questions short and
simple.
• Help him organize and get started on an
activity.
• Bring in family pictures and personal items
from home.
• Limit the number of visitors to 2-3 at a time.
• Give him frequent rest periods when he has
problems paying attention.

COGNITIVE LEVEL VI
CONFUSED AND APPROPRIATE
A person at this level may:
• be somewhat confused because of memory
and thinking problems, he will remember the
main points from a conversation, but forget
and confuse the details. For example, he may
remember he had visitors in the morning, but
forget what they talked about;
• follow a schedule with some assistance, but
becomes confused by changes in the routine;
• know the month and year, unless there is a
severe memory problem;
• pay attention for about 30 minutes, but has
trouble concentrating when it is noisy or
when the activity involves many steps. For
example, at an intersection, he may be unable
to step off the curb, watch for cars, watch the
traffic light, walk, and talk at the same time;
• brush his teeth, get dressed, feed himself etc.,
with help;
• know when he needs to use the bathroom;
• do or say things too fast, without thinking first;
• know that he is hospitalized because of an injury,
but will not understand all of the problems he is
having;
• be more aware of physical problems than
thinking problems;
• associate his problems with being in the hospital
and think that he will be fine as soon as he goes
home.

What family/friends can do at Cognitive
Level VI:
• You will need to repeat things. Discuss things
that have happened during the day to help the
individual improve his memory.
• He may need help starting and continuing
activities.
• Encourage the individual to participate in all
therapies. He will not fully understand the extent
of his problems and the benefits of therapy.

COGNITIVE LEVEL VII
AUTOMATIC AND APPROPRIATE
A person at this level may:
• follow a set schedule;
• be able to do routine self care without help, if
physically able. For example, he can dress or feed
himself independently; have problems in new
situations and may become frustrated or act
without thinking first;
• have problems planning, starting, and following
through with activities;
• have trouble paying attention in distracting or
stressful situations. For example, family
gatherings, work, school, church, or sports
events;
• not realize how his thinking and memory
problems may affect future plans and goals.
Therefore, he may expect to return to his
previous lifestyle or work;
• continue to need supervision because of
decreased safety awareness and judgment. He
still does not fully understand the impact of
his physical or thinking problems;
• think slower in stressful situations;
• be inflexible or rigid, and he may seem
stubborn. However, his behaviors are related
to his brain injury;
• be able to talk about doing something, but will
have problems actually doing it.

COGNITIVE LEVEL VIII
PURPOSEFUL AND APPROPRIATE
A person at this level may:
• realize that he has a problem in his thinking
and memory;
• begin to compensate for his problems;
• be more flexible and less rigid in his thinking.
For example, he may be able to come up with
several solutions to a problem;
• be ready for driving or job training evaluation;
• be able to learn new things at a slower rate;
• still become overloaded with difficult,
stressful or emergency situations;
• show poor judgment in new situations and
may require assistance;
• need some guidance to make decisions;
• have thinking problems that may not be
noticeable to people who did not know the
person before the injury.

What family/friends can do at Cognitive
Levels VII/VIII
• Treat the person as an adult by providing
guidance and assistance in decision making.
His opinions should be respected.
• Talk with the individual as an adult. There is
no need to try to use simple words or
sentences.
• Be careful when joking or using slang, because
the individual may misunderstand the
meaning. Also, be careful about teasing him.
• Help the individual in familiar activities so he can
see some of the problems he has in thinking,
problem solving, and memory. Talk to him about
these problems without criticizing. Reassure him
that the problems are because of the brain injury.
• Strongly encourage the individual to continue
with therapy to increase his thinking, memory
and physical abilities. He may feel he is
completely normal. However, he is still making
progress and may possibly benefit from
continued treatment.
• Be sure to check with the physician on the
individual's restrictions concerning, driving,
working, and other activities. Do not just rely on
him for information, since he may feel he is
ready to go back to his previous lifestyle.
• Discourage him from drinking or using drugs,
due to medical complications.
• Encourage him to use note taking as a way to
help with his remaining memory problems.
• Encourage him to carry out his self-care as
independently as possible.
• Discuss what kinds of situations make him angry
and what he can do in these situations.
• Talk with him about his feelings.
• Learning to live with a brain injury can be
difficult and it may take a long time for the
individual and family to adjust. The social worker
and/or psychologist will provide the
family/friends with information regarding
counseling, resources, and/or support
organizations.

© Los Amigos Research and Educational Institute
(LAREI), 1990

Disclaimer: Information presented on this page is
for specific health education purposes only. Persons
should consult qualified health professionals
regarding specific medical concerns or treatment.
Each clinician caring for the patient is responsible
for determining the most appropriate care.