This assessment of brain function is used sometimes instead of the Glasgow Coma Scale. It is also useful in evaluating patients later, giving an idea of the level of disability. Rancho Los Amigos is a rehabilitation facility in Southern California in the United States where thousands of brain-damaged patients have been rehabilitated.
The Scale has eight parts.
Cognitive Level I :: No Response
A person at this level will:
not respond to sounds, sights, touch or movement
Cognitive Level II :: Generalised Response
A person at this level will:
begin to respond to sounds, sights, touch or movement
respond slowly, inconsistently, or after a delay
respond in the same way to what he hears, sees or feels. Responses may include chewing, sweating, breathing faster, moaning, moving and/or increasing blood pressure
Cognitive Level III :: Localised Response
A person at this level will:
be awake on and off during the day
make more movements than before
react more specifically to what he sees, hears or feels. For example, he may turn towards a sound, withdraw from pain, and attempt to watch a person move around the room
react slowly and inconsistently
begin to recognize family and friends
follow some simple directions suck as "Look at me" or "squeeze my hand"
begin to respond inconsistently to simple questions with "yes" or "no" head nods
Cognitive Level IV :: Confused-Agitated
A person at this level may:
be very confused and frightened
not understand what he feels, or what is happening around him
overreact to what he sees, hears or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion
be restrained so he doesn't hurt himself
be highly focused on his basic needs; i.e., eating, relieving pain, going back to bed, going to the bathroom, or going home
may not understand that people are trying to help him
not pay attention or be able to concentrate for a few seconds
have difficulty following directions
recognize family/friends some of the time
with help, be able to do simple routine activities such as feeding himself, dressing or talking
Cognitive Level V :: Confused-Inappropriate : Non-Agitated
A person at this level will:
be able to pay attention for only a few minutes
be confused and have difficulty making sense of things outside himself
not know the date, where he is or why he is in the hospital
not be able to start or complete everyday activities, such as brushing his teeth, even when physically able. He may need step-by-step instructions
become overloaded and restless when tired or when there are too many people around
have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury
try to fill in gaps in memory by making things up (confabulation)
may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity
focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home
Cognitive Level VI :: Confused-Appropriate
A person at this level will:
be somewhat confused because of memory and thinking problems, he will remember the main points from a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about
follow a schedule with some assistance, but becomes confused by changes in the routine
know the month and year, unless there is a serious memory problem
pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time
brush his teeth, get dressed, feed himself etc., with help
know when he needs to use the bathroom
do or say things too fast, without thinking first
know that he is hospitalized because of an injury, but will not understand all the problems he is having
be more aware of physical problems than thinking problems
associate his problems with being in the hospital and think he will be fine as soon as he goes home
Cognitive Level VII :: Automatic-Appropriate
A person at this level will:
follow a set schedule
be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have problems in new situations and may become frustrated or act without thinking first
have problems planning, starting, and following through with activities
have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events
not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work
continue to need supervision because of decreased safety awareness and judgment. He still does not fully understand the impact of his physical or thinking problems
think slower in stressful situations
be inflexible or rigid, and he may be stubborn. However, his behaviors are related to his brain injury
be able to talk about doing something, but will have problems actually doing it
Cognitive Level VIII :: Purposeful-Appropriate
A person at this level will:
realize that he has a problem in his thinking and memory
begin to compensate for his problems
be more flexible and less rigid in his thinking. For example, he may be able to come up with several solutions to a problem
be ready for driving or job training evaluation
be able to learn new things at a slower rate
still become overloaded with difficult, stressful or emergency situations
show poor judgment in new situations and may require assistance
need some guidance making decisions
have thinking problems that may not be noticeable to people who did not know the person before the injury
Clearly, some parts of this scale will be used with a person just after a traumatic injury, with others coming into play as the person recovers. Patients who were never in a coma, or with moderate TBI might be partway along this continuum at the beginning. Some people with mild TBI may be at Cognitive Level VII or VIII, but not realize this is from their head injury, particularly if they never received medical care. They may know it is post-concussion, but it will still be difficult for them to deal with unless they get proper help, and their family and friends are supportive.
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