8.3 Ranchos Los Amigos – Level V and VI (RLA 5-6)

Case Study (continued)

A 16 year old male was admitted to rehabilitation following a two week stay in an acute care facility.  He had been hit by a car while inline skating home from school (the teenager was not wearing a helmet). The patient underwent a craniotomy shortly after admission to hospital.  The patient is an RLA-V.

8.3.1   Typical Presentation of RLA-V

How would an RLA-V typically present?

A patient who has been diagnosed at RLA-V (Confused Inappropriate) and VI (Confused Appropriate) may:

  • Continue to demonstrate inappropriate responses to environmental stimuli.
  • Demonstrate reduced information processing capacity relative to the amount, rate and duration, and complexity of information provided.
  • Not be able to perform elementary tasks such as dressing, bathing and feeding.
  • Be vulnerable to outside variables and lack the internal mechanism to modulate responses.
  • Sometimes react to the environment or situations in an exaggerated manner.

8.3.2   Treatment of RLA-V

How should an RLA-V be treated?

Treatment goals for an RLA-level V (Confused Inappropriate) or VI (Confused Appropriate)

include 60:

  1. Structure- oriented approach is most effective.
  2. At this stage, discipline-specific goals can be established.
  3. Tasks must structured by manipulating the stimulus parameters (i.e., amount, rate, complexity and duration of input).
  4. Functional tasks must be simplified into sequential steps.
  5. As cognitive capacity increases, structure can be gradually reduced.

Treatment strategies include:

  1. Environment should remain constant in terms of locations of objects.
  2. Memory aids should be provided within the patients’ vision.
  3. Environmental distractions should be minimized.
  4. The same staff should treat the patient where possible.
  5. All personnel should provide orienting information at the beginning or end of each session.


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