Rancho Los Amigos Levels of Cognitive Functioning Scale


Level 4: confused - agitated

As the brain improves, it begins to “wake up” and may have difficulty controlling the level of response to the environment. This is called “agitation.” You will see the patient will have poor memory and be confused most of the day. At this level, the safety of the patient is the biggest priority. The team may suggest certain ways to decrease the risk of falls and pulling at medical tubes.

The patient may cry, yell or scream, wave their arms around, or move about in bed as they react to their environment — even after the stimulus is removed. They may hit out at others or may try to remove tubes or try to climb out of bed. Either they are awake and active or asleep. This can be scary for you and the patient. At this time, the patient would benefit from a routine to help to manage the behaviour.

The patient cannot focus on tasks for a long time. If there is too much happening, such as many visitors, the patient may become more confused or agitated. The only memories they have are for things that happened before the head injury.

If the patient is able to speak, they may use the wrong words, mix up the order of words or tell stories that do not make sense. They are not able to find the right words as they are not yet able to think before they act.

Suggestions for the family for level 4

  1. This stage is a sign of improvement and part of getting better.
  1. When the patient is relaxed, use this time to help them improve their ability to respond correctly. Work in a quiet environment so that the patient does not become distracted.
  1. Ask them to try simple tasks like brushing their teeth or washing their face. Place the objects they need within reach. Do not expect them to do the task but be pleased if they do.
  1. Do not startle the patient, especially when you wake them up from sleep.
  1. If you visit the patient during a meal, give them only one choice of food at a time and let them do as much for themselves as possible.
  1. There should be no more than two visitors at any time. Do not talk to the head-injured patient, play the radio, feed them, stroke their arm and have many visitors all at the same time. All this noise will make them more agitated. They do best with one “focus” at a time.
  1. If the patient is not talking, use other ways of communication such as head movements or finger tapping to show “yes” or “no”. The Speech Language Pathologist and/ or Occupational Therapist will be able to help to direct you with this.
  1. If the patient says things that are not correct, remind them of the true facts. If they say: “I am at work right now”, do not agree, but gently and clearly tell them how they were injured and that they are in Sunnybrook Hospital. Repeat this once if necessary. If they continue to insist that they are at work, do not argue. Change the topic to distract them. For example, comment on the weather or tell them what they are having for lunch.
  1. If the patient becomes agitated, stay with them until they calm down. Visiting by family members can be a good thing. Touch them, speak in a soft voice, help wash their face or body with warm water, or play soft music. If they are allowed to eat, try giving drink or food to calm them down.
  1. At this level, patients are often not able to cooperate. If they shout or cry it does not always mean that the patient is in pain. Anger, swearing or crying is the way the patient acts to stimuli. They are not aware of how they are behaving.
  1. If there are swallowing issues, follow the directions of the speech pathologist who will recommend the safest food textures for eating.