Rancho Los Amigos Levels of Cognitive Functioning Scale

Levels 5 & 6


Level 5: Confused - inappropriate - non-agitated

The patient may be more awake and can respond to simple commands. They are able to focus longer, but will need to be told what to do several times. The patient is easily distracted so may need to be asked several times to finish a task. They have memories of events in the past but they will not have clear memories of events since the injury. For example, they may not recall what you told them five minutes ago. They may be able to do simple tasks that they have done in the past, like eating and dressing. They are not able to learn new information, and may seem to have lost their manners. They may show innapropriate behaviour, such as sexual comments or actions, or may eat their meals with poor manners.

Level 6: Confused - appropriate

The patient follows simple directions most times they are asked. Your loved one is able to recall how to do things like feeding, dressing and bathing. Memory for events since their injury is still poor, so learning new information is hard. The patient is more aware of time and place. Their attention can sometimes be held for as long as 30 minutes. During that time they will talk and behave more appropriately, although they may act like a machine and give the same answers every time. They may still be confused at times. They are not safe to leave the unit alone as they do not remember the way back to their room. They may seem selfish and care only about themselves.

Suggestions for the family for levels 5 and 6

  1. Go over information about family and friends. Use the photo albums as a way to help their memory.
  1. Poor memory means that the patient will not remember the injury or how it was caused. If you and the care team feel that your family member is ready, tell them any painful information related to the incident that brought them to hospital. This information could be that someone was killed or badly injured. Being upset may be temporary. While he or she can understand facts, the ability to grieve returns much later.
  1. Help your family member recall information that is not easy to remember. Ask them questions and if the correct answer is not given, provide some clues. If clues do not work, then give the missing information.
  1. Ball games and simple card games are all good for learning. If your family member’s performance is good some days but not so good other days-be patient.
  1. Your family member may sometimes confuse kissing, hugging or stroking as sexual messages. If they do this, gently tell them that this is not appropriate. If you want to show affection and encouragement, tell them they did well and limit physical contact to pats on the shoulder or pecks on the cheek.
  1. Praise everything that your family member is able to do. Allow them to do only one task at a time.
  1. Help them with “homework” that is given by the team. Either help the patient write in a journal or write about your own experience being with your loved one-in the journal.
  1. Your family member may need to rest during the day, but they may not know it. Do not ask if they are tired but allow for rest periods.
  1. Ask the patient to tell you about things as soon as they have done a task. Ask what he or she watched on television and have the patient write this down if possible.
  1. Your family member may not be able to sort out time or events that have happened after they came to hospital. Calmly and gently tell them the truth. The patient may have false ideas about the time just before they came to hospital. Do not argue about false ideas with the patient. Talk about other things instead.
  1. Some tasks may still be difficult. Ask the patient to describe the steps they would perform when doing a task, such as cleaning their teeth, and then have them do it.
  1. Slowly increase independence and make a routine to help the patient remember.