Los Amigos Scale of Cognitive Functioning
From the Head
Trauma Research Project
New York University Medical Center Institute of Rehabilitation Medicine
Physicians discharge patients from intensive care units (ICU) once their
vital signs are stable for a period of time and they are no longer at
risk of acute medical and surgical problems, such as bleeding or rapidly
increasing intracranial pressure.
hospitals have special units for patients with various neurologic problems.
Others offer acute brain injury rehabilitation programs. These programs
are designed to assess the physical, cognitive, and behavioral status
of patients, establish specific treatment, and prevent complications.
Rehabilitation staff members consider each patient's potential carefully
and devise individual plans.
members and friends know that discharge from the ICU is a step forward.
They are relieved that the patient's condition has stabilized to the
point where he or she no longer needs intense observation. Still, they
may feel anxious about leaving the security of the ICU. They have come
to know and trust the ICU staff and now must get acquainted with a whole
new group of caregivers. It is reassuring to know that the staff is
aware of these feelings and is available to help patients and families
become accustomed to a new unit.
patients are in a semi-comatose or confused and restless state when
they are discharged from the ICU. Assessing their physical problems
may not be difficult, but cognitive and behavioral deficits are harder
to pinpoint. To evaluate these aspects, the Rancho Los Amigos Scale
of Cognitive Functioning, (RLA) named for the center where it was developed,
is used in acute rehabilitation settings throughout the country.
following is a brief description of the Rancho Los Amigos Scale of Cognitive
1 - No response. The patient appears to be in a very deep sleep
or coma and does not respond to voices, sounds, light, or touch.
2 - Generalized response. The patient moves around, but movement
does not seem to have a purpose or consistency. Patients may open their
eyes but do not seem to focus on anything in particular.
3 - Localized response. Patients begin to move their eyes and look
at specific people and objects. They turn their heads in the direction
of loud voices or noise. Patients at level 3 may follow a simple command,
such as "Squeeze my hand."
4 - Confused and agitated. The patient is very confused and agitated
about where he or she is and what is happening in the surroundings.
At the slightest provocation, the patient may become very restless,
aggressive, or verbally abusive. The patient may enter into incoherent
5 - Confused, inappropriate but not agitated. The patient is confused
and does not make sense in conversations but may be able to follow simple
directions. Stressful situations may provoke some upset, but agitation
is no longer a major problem. Patients may experience some frustration
as elements of memory return.
6 - Confused but appropriate. The patient's speech makes sense,
and he or she is able to do simple things such as dressing, eating,
and teeth brushing. Although patients know how to perform a specific
activity, they need help discerning when to start and stop. Learning
new things may also be difficult.
7 - Automatic, appropriate. Patients can perform all self-care activities
and are usually coherent. They have difficulty remembering recent events
and discussions. Rational judgments, calculations, and solving multi-step
problems present difficulties, yet patients may not seem to realize
8 - Purposeful and appropriate. At this level, patients are independent
and can process new information. They remember distant and recent events
and can figure out complex and simple problems.
patients improve after a brain injury, they may move from one level
to the next, but often demonstrate characteristics of more than one
level at a time. Depending on the extent and type of injury, they may
remain at any one level for an extended period. Using information from
this scale, the health care team can begin treatment that will help
develop skills and promote appropriate behavior. Health care professionals
often suggest the following simple measures to family and friends while
the patient is still in a coma: Always talk as if the patient hears
you when you are nearby.
directly to the patient abut simple things and reassure him or her frequently.
events and noises in the surrounding area.
the patient what has happened and where he or she is.
and stroke the patient gently.
the patient who you are each time you approach the bedside.
his or her hand.
the patient's favorite music or tape a soothing message that can be
played when you are away from the bedside.
parents of young children, tape yourself singing or reading your child's
for Scoring the Glasgow Coma Scale
From the Head Trauma Research Project New York University Medical Center
Institute of Rehabilitation Medicine
Explanation of the Glasgow Coma Scale for the layman
the patient is partially stabilized in the emergency department of the
hospital, he or she is usually transferred to an intensive care unit
where assessment and treatment continue. Physicians commonly use a standardized
test, the Glasgow Coma Scale, to evaluate brain injuries.
rates three categories of patient responses; eye opening, best verbal
response, and best motor response. Levels of responses indicate the
degree of nervous system or brain impairment. Eye opening tests indicate
the function of the brain's activating centers.
patient's eyes may open spontaneously, only on verbal request, or only
with painful stimulation. Best verbal response indicates the condition
of the central nervous system within the cerebral cortex. The patient
may be able to speak normally and be oriented to time and place, or
he or she may be disoriented and use inappropriate words.
the other end of the scale, the patient may only make incomprehensible
sounds or no sound at all.
motor response tests examine a patient's ability to move arms and legs.
Responses may vary from the ability to move about on command to the
ability to move only in response to pain.
element of the Glasgow Coma Scale is rated using "1" as the lowest possible
score in each category. Physicians classify brain injuries as mild,
moderate, or severe, using these scores. The
Score is obtained by adding the eye opening, verbal response, and motor
Opening Response E Score Characteristics
1 Eyes always closed; not attributable to ocular swelling
To pain 2 Eyes open in response to painful stimulus
To speech 3 Eyes open in response to speech or shout; does not imply
patient obeys command to open eyes
Spontaneous 4 Eyes open; does not imply intact awareness
pressure on nail bed and suprorbital pressure)
M Score Characteristics
No Response 1
No motor response to pain
Extension 2 Extension at elbow
Abnormal flexion 3 Includes preceding extension, stereotyped flexion
posture, extreme wrist flexion, abduction of upper arm, flexion of fingers
over thumb: see administration instruction; if unsure, score as withdrawal
Withdrawal 4 Normal flexor withdrawal; no localizing attempt to remove
Localizes pain 5 Attempt made to remove stimulus, e.g., hand moves above
chin toward supraocular stimulus Obeys commands 6 Follows simple commands
V Score Characteristics
Response 1 No sounds
Incomprehensible 2 Moaning, groaning, grunting; incomprehensible Inappropriate
3 Intelligible words, but not in a meaningful exchange; e.g., shouting,
swearing; no meaningful conversation
Confused 4 Responds to questions in conversational manner, but responses
indicate varying degrees of disorientation and confusion
Oriented 5 Normal orientation to time, place, person; appropriate conversation
Glasgow Coma Scale Score = E+M+V (3-15)
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Brain Injury Association Of Connecticut
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Rocky Hill, CT 06067
Phone: (203) 721-8111 or 1-800-278-8242
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head injury. We endeavor to inform and believe that you have the right
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