Rancho Los Amigos Levels of Cognitive Functioning Scale

Levels 1, 2 & 3


Level 1: no response

The brain injured patient looks as if they are in a very deep sleep and does not wake up even when you talk to them or stimulate them. Your loved one may be in the Intensive Care Unit and may be attached to a machine to help with breathing.

Level 2: generalized response

The patient seems to be asleep most of the time. They may wake up slowly to noises, movement or touch. The patient may make a face or groan when touched, such as when a nurse gives a needle, or takes blood pressure.

The patient may start to do simple things spontaneously or when you ask of them, such as “close your eyes”, “stick out your tongue” or “squeeze my hand”. These are good signs, but you should ask the nurse or therapists about better ways to judge if the patient is consistently following commands.

Level 3: localized response

The patient is more awake for longer periods during the day. The ability to respond to stimuli and to move the limbs and body are happening more often. For example, this might mean moving an arm or leg in response to pain, following a command when asked, or reacting to a sound or patient.

At this level, responses may not be the same every day, so the important thing to look for is consistency.

Suggestions for the family for level 1, 2 or 3

  1. Each time you see the patient, say who you are. Tell them the day, date and time. Tell them in a basic way how they were hurt, and that they are now getting better.
  1. Speak to the patient in a calm, slow, normal voice. The patient is usually able to hear you, even if they cannot speak to you. Talk about things that are familiar and important to them, even if you are not sure if they understand what is being said.
  1. Show the patient pictures of whom and what you are talking about. Take some “ordinary” pictures such as photos of their house, friends and family, special events or memories. These photos will help the patient to think about ordinary life and familiar things.
  1. Play music the patient would enjoy, for short periods of time (Maximum 5-10 minutes at a time).
  1. Turn off or lower the lights for short periods so that the patient may respond better by noticing a difference when the lights are on.
  1. Ask the patient to follow simple instructions such as: “raise your arm”, “close your eyes”, “stick out your tongue”, “show me your teeth”, etc. Give one direction at a time and allow plenty of time for the response. This is because the brain will be processing instructions very slowly at this level.
  1. Avoid too much stimulation at once by having only two visitors at a time. Explain to the visitors how to talk calmly with your family member. Ask for visitors to take turns and rotate so that there is the right amount of stimulation for the patient every day. Making a visitor’s schedule in the hospital is very helpful.
  1. As the patient gradually becomes more alert and awake, start a simple routine. For example, try to get your loved one to wash their face every day with a washcloth.
  1. If the patient is alert enough, you can ask them questions about something that happened in the past that has a “yes” or “no” answer. An example of this is saying the date of their birthday and asking if this is correct. Allow them time to respond, as their reaction time will be slow.
  1. Go slowly, as giving too much stimulation will not help the patient and their brain heal faster.
  1. Be careful not to yell as if they cannot hear you. The communication problem is in the brain’s ability to process information, not with the hearing. Speaking loudly will not help get the message through.
  1. A diary or notebook can be used by visitors to record events of the patient’s day. Later, this diary can be helpful in improving memory. The diary can also be a way in which the family and the health care team communicate with each other.
  1. Look after yourself and the family by accepting help from friends and relatives – no matter how small the offer of help is. Getting help will reduce some of your stress and allow friends and family to feel useful. When the patient is more awake, they will need you more, so pace yourself at this stage by getting enough sleep, going home to have a shower, doing some physical exercise and eating healthy food.
  1. Meet with the hospital staff and ask questions about the brain injury, and take notes to help you remember. They may not have all the answers about recovery time, especially when it is soon after the injury. Tell the hospital staff about your loved one’s job, hobbies, and the things that make them unique. This will help the staff see your loved one as the patient they were before the injury.