Ranchos Los Amigos Scale of Cognitive Recovery: 8 Levels

Ranchos Los Amigos Scale

With the Ranchos Los Amigos scale, you can describe the level of activity of a person with brain injury. The levels seem simple and straightforward, but in real life, not everyone moves smoothly on each level.

A person with brain injury can move from level 2 to level 4 and never show true level 3 activity. A person with brain injury can reach level 3 and never go beyond that point. Even if a person reaches level 8, it does not necessarily mean that it is exactly what it used to be. There may be minor changes.

There are brief description of the eight stages.

Level 1: No reaction:

The person with brain injury is unconscious. They seem to be sleeping. They do not respond to any stimulus.

This comatose state can take seconds, minutes, hours, days, weeks or months.

Level 2: Generalized response:

The person with brain injury will react inconsistently and without purpose. The answer is often a broad body movement or confusing words, and the answer is usually the same regardless of the stimulus.

The 1st reaction is usually to deep pain.

Level 3: Localized response:

The person with brain injury improves. They are reacting more specifically to different stimuli, but the reaction is different each time.

For example, they may occasionally turn their heads in the direction of a speaker’s voice. You may have a vague awareness of your body.

Sometimes they follow simple orders like “close your eyes” or “press my hand”.

Level 4: Confused / Excited:

The person with brain injury has become very active but still cannot understand what is happening. The behavior could be strange.

They could scream or try to remove the feeding tube. They can be hostile and non-cooperative, but they don’t act out of anger or fear. This is a reaction to your confusion.

Level 5: Confused / Inappropriate:

The person with brain injury is less agitated. They respond more consistently to simple commands. When the commands are more complicated, they are confused and react incorrectly.

They can get restless in a noisy or “busy” environment. They will not take the first step. They respond better to body aches and pains, to their own well-being and closeness with family members.

The memory is badly damaged, and they cannot learn new information. They run the risk of “migrating” in this level.

Read here: Allen Cognitive Levels (ACL)

Level 6: Confused / Reasonable:

The person with brain injury is motivated, but it depends on other people to show the way. The reactions will be more appropriate.

If they don’t feel well, they will complain. They begin to recognize the therapy staff and are much more aware of themselves and their family.

You can easily follow simple instructions. The memory of the past has greatly improved, but the memory of recent events is still damaged.

Level 7: Automatic/appropriate:

The person with brain injury seems to be acting properly in the hospital and at home. They know who they are, where they are, the date and time.

Everything seems fine, but things are still not quite right. They go through everyday life automatically like a robot. Although they can get dressed, washed and fed without help, they need guidance to be safe.

Judgment and problem-solving skills are still damaged and cannot make realistic plans for the future.

Level 8: Appropriate / Reasonable :

Finally! The person with brain injury remembers how the past coincides with the future. They are independent and can work well in society.

You may still have difficulty thinking, judging and learning, especially in high stress situations, unusual situations or emergencies.

You can actively participate in a vocational rehabilitation program and learn a new way of life.


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