1.6 Rancho Los Amigos Level of Cognitive Functioning Scale

The patient at time of admission to rehabilitation was deemed to be an RLA-IV.  On the rehabilitation unit he is argumentative and is not easily re-directed. His voice will quickly escalate in volume and he will begin yelling.  He makes less sense when he is agitated.  Unfortunately, he cannot be physically re-directed as he will strike out at staff or attempt to pull them in to bite them.  His most clear vocalizations are shouted profanity which is disturbing to others on the unit.

1.6.1 Description of RLA of Cognitive Functioning Scale

Describe the Rancho Los Amigos Levels of Cognitive Functioning Scale

  • Describes 8 stages of cognitive function that brain injury patients typically progress.
  • Not an outcome measure but rather a global index used to describe awareness, environmental interaction and behavioural competence.
  • Used to monitor recovery.
  • The Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS) was intended to provide a description of 8 stages of cognitive function through which brain injured patients typically progress during their stay in hospital and acute rehabilitative care 24;25
  • It was not developed as a scale and is not considered to be an outcome measure. 
  • It is a global index used to describe awareness, environmental interaction and behavioural competence 26;27.
  • It is used to monitor recovery and classify outcome in patients with brain injury 28.

For a more detailed discussion of the RLA plese see ERABI/Assessment of Outcomes Following Acquired/Traumatic Brain Injury


What are the various levels of the Rancho Los Amigos Levels of Cognitive Functioning and what does this indicated about the individual?24




Help Needed


No Response

Total Assistance


Generalized Response

Total Assistance


Localized Response

Total Assistance



Maximal Assistance


Confused, Inappropriate Non-Agitated

Maximal Assistance


Confused, Appropriate

Moderate Assistance


Automatic, Appropriate

Minimal Assistance for Daily Living Skills


Purposeful, Appropriate

Stand-By Assistance


Purposeful, Appropriate

Stand-By Assistance on Request



Modified Independent



1.6.2  Advantages and Disadvantages of RLA LCFS

Describe Strengths and Weaknesses of Ranchos Los Amigos LCF Scale.


  • Provides a quick and simple snapshot of level of recovery.
  • Useful for making quick comparisons between groups.
  • Simplicity and utility have resulted in widespread use


  • Lack of standardization, which effects interobserver reliability.
  • The RLA-LCFS is a quick and simple way to provide a snapshot of an individual’s level of recovery.
  • Its simplicity and utility have contributed to its widespread use within the United
  • States 29;30.
  • However, at present there is no standardized method to derive an LCFS rating.
  • It focuses on the impact of cognitive dysfunction on arousal and overall behaviour, but does not provide information regarding specific domains of cognitive impairment 31.
  • There is relatively little published evidence to support the reliability or validity of the LCFS.

1.6.3   Clinical Presentation of Ranchos Los Amigos – Level IV (RLA-IV)

How would an RLA-IV typically present?

A patient who has been diagnosed at RLA-IV may:

  • be confused or frightened;
  • not be able to understand what he feels;
  • not be able to understand what is happening around him;
  • over react to what he is seeing or hearing;
  • be seen hitting, screaming, using abusive language, etc;
  • need to be restrained to avoid injuring himself;
  • not understand that people are trying to help him;
  • have difficulty following instructions; not be able to focus for more than a few minutes;
  • not be able to follow direction or have difficulty when expected to follow direction;
  • show difficulties in recognizing family and friends;
  • be able to feed or dress self with assistance;
  • have difficulty talking 32

1.6.4   Treatment of Patient with Ranchos Los Amigos – Level IV (RLA-IV)

How should an RLA-IV be treated?

1.   Treatment goals for an RLA-level IV (Confused –Agitated) include:

  • Decrease intensity, duration and frequency of agitation;
  • Increase attention to the environment;
  • Team goal is to have the patient advance to a higher cognitive level.

2.   Treatment strategies for patients include:

  • Must not to be left alone;
  • The patient ‘s room must be kept to a minimum from noise and traffic;
  • Must be often familiarized with basic information;
  • Physical reassurance by talking to and touching the patient (if he does not object to         physical contact);
  • Accommodation in a highly-structured setting;
  • Remove patient from the group or change activity if his agitation increases;
  • Freedom of movement should be provided to control outbursts;
  • Stimulating simple self-care tasks and participation (eating, brushing hair, washing face);
  • Use of psychotropic medications as a last resort 32