Rancho Los Amigos Levels

Family Guide to the Rancho Los Amigos 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, judgment, 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 Levels of Cognitive Functioning is an evaluation tool used by the rehabilitation team. The eight levels describe the pattern 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 his or her own rate, depending on a variety of factors, including 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 only to a certain level and no farther.

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 is 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:

• does 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;
• respond in the same way to what he or she 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 or she sees, hears, or feels. For example, he or she 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 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 or she is, why he or she 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 or her rest periods. He or she will tire easily.
• Engage him or her in familiar activities, such as listening to his or her favorite music, talking about family and friends, reading out loud to him or her, watching TV, combing his or her hair, putting on lotion, etc.
• He or she 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 or she feels or what is happening around him or her;
• overreact to what he or she sees, hears, or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion;
• be highly focused on his or her basic needs, i.e., eating, relieving pain, going back to bed, going to the bathroom, or going home;
• not understand that people are trying to help him or her;
• 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 him/herself, dressing, or talking.

What family/friends can do at Cognitive Level IV:

• Tell the person where he or she is and reassure him or her that he or she is safe.
• Bring in family pictures and personal items from home, to make him or her feel more comfortable.
• Allow him or her as much movement as is safe.
• Take him or her for rides in a wheelchair, when this has been approved by the treating team.
• Experiment to find familiar activities that are calming to him or her as listening to music, eating, etc.
• Do not force him or her to do things. Instead, listen to what he or she wants to do and follow his or her lead, within safety limits.
• Since he or she often becomes distracted, restless, or agitated, you may need to give him or her 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 him/ herself;
• not know the date, where he or she is, or why he or she is in the hospital;
• not be able to start or complete everyday activities, such as brushing his or her teeth, even when physically able. He or she may need step-by-step instructions;
• become overloaded and restless when tired or when there are too many people around;
• a very poor memory. (He or she will remember past events from
• before the accident better than new information he or she has been told since the injury.);
• appear to “make things up” to try to fill in gaps in memory;
• 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 or she will remember what you tell him or her.
• Tell him or her the day, date, name and location of the hospital, and why he or she is in the hospital when you first arrive and before you leave.
• Keep comments and questions short and simple.
• Help him or her 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 or her frequent rest periods when he or she 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 or she will remember the main points from a conversation, but forget and confuse the details. For example, he or she may remember he or she 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 or she may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time;
• brush his or her teeth, get dressed, feed him/herself etc., with help;
• know when he or she needs to use the bathroom;
• do or say things too fast, without thinking first;
• know that he or she is hospitalized because of an injury, but will not understand all of the problems he or she is having;
• be more aware of physical problems than thinking problems;
• associate his or her problems with being in the hospital and think that he or she will be fine as soon as he or she 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 remember recent events and activities.
• He or she may need help starting and continuing activities.
• Encourage the individual to participate in all therapies. He or she will not fully understand the extent of his or her 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 or she can dress or feed him/herself 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 or her thinking and memory problems may affect future plans and goals. Therefore, he or she may expect to return to his or her previous lifestyle or work;
• continue to need supervision because of decreased safety awareness and judgment. He or she still does not fully understand the impact of his or her physical or thinking problems;
• think more slowly in stressful situations;
• be inflexible or rigid, and he or she may seem stubborn. However, his or her behaviors are related to the 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 or she has problems with his or her thinking and memory;
• begin to compensate for his or her problems;
• be more flexible and less rigid in his or her thinking. For example, he or she 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; show respect for his or her opinion when attempting to provide guidance and assistance in decision making.
• Talk with the individual as an adult. There is no need to try to use simple words or sentences.
• Because the individual may misunderstand joking, teasing, or slang language, be careful to check for understanding when using humor or other abstract language.
• Encourage the individual to be as independent as is safe. Help him or her with activities when he or she shows problems with thinking, problem solving, and memory. Talk to him or her about these problems without criticizing. Reassure him or her that the problems are because of the brain injury.
• Strongly encourage the individual to continue with therapy to increase his or her thinking, memory, and physical abilities. He or she may feel he or she is completely normal. However, he or she 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 rely on the brain injured individual for information, since he or she may feel ready to go back to his or her previous lifestyle.
• Discourage him or her from drinking or using drugs, due to medical complications.
• Encourage him or her to use note taking as a way to help with memory problems.
• Encourage him or her to carry out his/her self care as independently as possible.
• Discuss what kinds of situations make him or her angry and what he or she can do in these situations.
• Talk with him or her about his or her feelings.
• Learning to live with a brain injury is difficult and it may take a long time for the individual and family to adjust. The social worker and/or psychologist will provide family members and friends with information regarding counseling, resources, and support organizations.

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

See more information included in Module 1: Introduction to Traumatic Brain Injury.