Introduction to Disorders of Consciousness

The healthcare team will conduct assessments with the person recovering from a disorder of consciousness. Here we provide information about two highly regarded and widely used assessment tools.

Coma Recovery Scale

Within a rehabilitation environment, clinicians may utilize the Coma Recovery Scale (PDF) as a tool to measure changes in arousal and awareness of the environment for an individual in disorders of consciousness.

Rancho Los Amigos Levels of Cognitive Functioning Scale

The Rancho Los Amigos Levels of Cognitive Functioning Scale (Revised Version) outlines functional abilities with related levels of required care across 10 levels.

The Rancho Los Amigos Levels of Cognitive Functioning Scale (Revised Version) outlines functional abilities with related levels of required care across 10 levels.

• Level 1 | No response: Total assistance
  • Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli
• Level 2 | Generalized response: Total assistance
  • Demonstrates generalized reflex response to painful stimuli
  • Responds to repeated auditory stimuli with increased or decreased activity
  • Responds to external stimuli with physiological changes generalized, gross body movement, and/or not purposeful vocalization
  • Responses noted above may be same regardless of type and location of stimulation.
  • Responses may be significantly delayed.
• Level 3 | Localized response: Total assistance
  • Demonstrates withdrawal or vocalization to painful stimuli
  • Turns toward or away from auditory stimuli
  • Blinks when strong light crosses visual field
  • Follows moving object passes within visual field
  • Responds to discomfort by pulling tubes or restraints
  • Responds inconsistently to simple commands
  • Responds directly related to type of stimulus
  • May respond to some persons, especially family and friends, but not to others
• Level 4 | Confused/agitated: Maximal assistance
  • Alert and in heightened state of activity
  • Purposeful attempts to remove restraints or tubes or crawl out of bed
  • May perform motor activities such as sitting, reaching, and walking, but without any apparent purpose or upon another’s request
  • Very brief and usually non-purposeful moments of sustained alternatives and divided attention
  • Absent short-term memory
  • May cry out or scream out of proportion to stimulus even after its removal
  • May exhibit aggressive or flight behavior
  • Mood may swing from euphoric to hostile with no apparent relationship to environmental events
  • Unable to cooperate with treatment efforts
  • Verbalizations are frequently incoherent and/or inappropriate to activity or environment.
• Level 5 | Confused, inappropriate, non-agitated: Maximal assistance
  • Alert, not agitated but may wander randomly or with a vague intention of going home
  • May become agitated in response to external stimulation and/or lack of environmental structure
  • Not oriented to person, place, or time
  • Frequent brief periods of non-purposeful, sustained attention
  • Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
  • Absent goal-directed, problem-solving, self-monitoring behavior
  • Often demonstrates inappropriate use of objects without external direction
  • May be able to perform previously learned tasks when structured and cues provided
  • Unable to learn new information
  • Able to respond appropriately to simple commands fairly consistently with external structures and cues
  • Responses to simple commands without external structure are random and non-purposeful in relation to command
  • Able to converse on a social, automatic level for brief periods of time when provided external structure and cues
  • Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.
• Level 6 | Confused, appropriate: Moderate assistance
  • Inconsistently oriented to person, time, and place
  • Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection
  • Remote memory has more depth and detail than recent memory
  • Vague recognition of some staff
  • Able to use assistive memory aide with maximum assistance
  • Emerging awareness of appropriate response to self, family, and basic needs
  • Moderate assist to problem solve barriers to task completion
  • Supervised for old learning, such as self-care
  • Shows carry over for relearned familiar tasks, such as self-care
  • Maximum assistance for new learning with little or no carry over
  • Unaware of impairments, disabilities, and safety risks
  • Consistently follows simple directions
  • Verbal expressions are appropriate in highly familiar and structured situations.
• Level 7 | Automatic, appropriate: Minimal assistance for daily living skills
  • Consistently oriented to person and place, within highly familiar environments
  • Moderate assistance for orientation to time
  • Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks
  • Minimal supervision for new learning
  • Demonstrates carry over of new learning
  • Initiates and carries out step to complete familiar personal and household routine but has shallow recall of what they have been doing
  • Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance
  • Superficial awareness of their condition but unaware of specific impairments and disabilities and the limits these place on their ability to safely, accurately and completely carry out their household, community, work, and leisure ADLs
  • Minimal supervision for safety in routine home and community activities
  • Unrealistic planning for the future
  • Unable to think about consequences of a decision or action
  • Overestimates abilities
  • Unaware of others’ needs and feelings
  • Oppositional or uncooperative
  • Unable to recognize inappropriate social interaction behavior
• Level 8 | Purposeful, appropriate: Stand-by assistance
  • Consistently oriented to person, place, and time
  • Independently attends to and completes familiar tasks for 1 hour in distracting environments
  • Able to recall and integrate past and recent events
  • Uses assistive memory devices to recall daily schedule, to-do lists, and record critical information for later use with stand-by assistance
  • Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance
  • Requires no assistance once new tasks and activities are learned
  • Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action
  • Thinks about consequences of a decision or action with minimal assistance
  • Overestimates or underestimates abilities
  • Acknowledges others’ needs and feelings and responds appropriately with minimal assistance
  • Depressed
  • Irritable
  • Low frustration tolerance and easily angered
  • Argumentative
  • Self-centered
  • Uncharacteristically dependent or independent
  • Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance
• Level 9 | Purposeful, appropriate: Stand-by assistance
  • Independently shifts back and forth between tasks and completes them accurately for at least 2 consecutive hours
  • Uses assistive memory devices to recall daily schedule, to-do lists and record critical information for later use with assistance when requested
  • Initiates and carries out steps to complete familiar personal, household, work, and leisure tasks independently and unfamiliar personal, household, work, and leisure tasks with assistance when
    requested
  • Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action, but requires standby assistance to anticipate a problem before it occurs and take action to avoid it
  • Able to think about consequences of decisions or actions with assistance when requested
  • Accurately estimates abilities but requires stand-by assistance to adjust to task demands
  • Acknowledges others’ needs and feelings and responds appropriately with stand-by assistance
  • Depression may continue.
  • May be easily irritable
  • May have low frustration tolerance
  • Able to self-monitor appropriateness of social interaction with stand-by assistance
• Level 10 | Purposeful, appropriate: Modified independent
  • Able to handle multiple tasks simultaneously in all environments but may require periodic breaks
  • Able to independently procure, create, and maintain own assistive memory devices
  • Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work, and leisure tasks, but may require more than usual amount of time and/or compensatory
    strategies to complete them
  • Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur, but may require more than usual amount of time and/or compensatory strategies
  • Able to independently think about consequences of decisions or actions, but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action
  • Accurately estimates abilities and independently adjusts to task demands
  • Able to recognize the needs and feelings of others and automatically respond in appropriate manner
  • Periodic periods of depression may occur.
  • Irritability and low frustration tolerance when sick, fatigued, and/or under emotional stress
  • Social interaction behavior is consistently appropriate.

In a coma, an individual demonstrates no wakefulness or responsiveness to any type of stimulation. Symptoms include:

• Their eyes remain closed.
• They show no response to pain or things they hear or feel.
• They demonstrate no movement.

When a patient is in a coma, you may hear your treatment team refer to this stage as Rancho Level 1.

With unresponsive wakefulness, an individual has periods of time when they are awake and will demonstrate generalized responses to stimulation. Generalized responses are behaviors that occur due to reflexes or happen automatically. An individual in this state may move, but all movements are reflexive and are not purposefully controlled.

It can be difficult for family members to determine whether a movement is voluntarily controlled or is an automatic, reflexive response. If you have any questions about the type of responses that your loved one is showing, please ask a member of your treatment team. When a patient is experiencing unresponsive wakefulness, you may observe some of the following behaviors:

• They open their eyes.
• They react to pain by posturing or pulling away.
• They show signs of hearing and reacting to sound. You may see them blink in response to a loud noise or turn their head or eyes in the direction of a noise.
• They reflexively blink in response to a visual threat.
• They make reflexive movements with their mouth, such as biting down on a toothbrush, coughing, and swallowing.

When a patient is experiencing unresponsive wakefulness, you may hear the treatment team refer to this stage as Rancho Level 2.

n a minimally conscious state, an individual has periods of wakefulness and will show purposeful responses in reaction to things happening around them. Purposeful responses are behaviors that show that an individual is gaining awareness of things happening to them and are beginning to interact with things in their environment.

When the patient is in a minimally conscious state, you may observe some of the following behaviors:

• They open their eyes and are awake for longer periods during the day.
• They react to pain by trying to remove whatever is causing them discomfort, such as pushing your hand away or pulling at a catheter.
• They follow simple one-step commands.
• They follow people moving around their room with their eyes.
• They reach for and grasp objects.
• They inconsistently and inaccurately answer simple yes/no questions.

When the patient is in a minimally conscious state, you may hear the treatment team refer to this stage as Rancho Level 3.

When an individual is conscious, they demonstrate purposeful interaction with their environment. The two behaviors used to determine whether an individual has emerged into a fully conscious state are:

• Consistent and accurate communication of yes/no responses
• Purposeful use of objects