Ranchos scale

Level I:

No response; total assistance. At this stage, people do not respond in any observable way to stimulation, including painful input.

Level II:

Generalized response; total assistance. At this stage, people do respond to stimulation, including painful input, but the response is generalized, meaning that people exhibit the same behavior no matter what type of input is received. The responses may include an increase or decrease in activity such as gross motor movements or vocalizations. Often the responses are delayed.

Level III

Localized response; total assistance. At this stage, people respond to stimulation, and the responses are becoming more specific to the input that is received, but these behaviors are still largely nonpurposeful. Examples may be withdrawal from painful stimuli, turning toward sounds, visually tracking moving objects, inconsistently following simple commands, and pulling at tubes.

Level IV

Confused, agitated; maximal assistance. At this stage, people are more active, but movements and actions are still not purposeful. Emotionally, people are often agitated and volatile and may be aggressive. They will also actively try to remove restraints or tubes. They have poor attention and no short-term memory. They will also not follow commands consistently, and their verbalizations are incoherent or unrelated to what is happening around them.

Level V

Confused, inappropriate, nonagitated; maximal assistance. At this stage, people are alert and agitation is seen less often, usually in response to overstimulation. People are able to follow simple commands, especially with support and cueing. They are better able to complete simple and familiar tasks with support. They are not able to learn new information and have severely impaired short-term memory. They are also not oriented and may wander.

Level VI

Confused, appropriate; moderate assistance. At this stage, people are becoming more oriented, although this is still inconsistent. Attention and memory are also improving with some ability to learn emerging, although they still need a great deal of support and assistance. They are better able to follow directions with less cueing and can participate more purposefully with activities, including self-care.

Level VII

Automatic, appropriate; minimal assistance for routine daily living skills. At this stage, people are able to complete many routine tasks with minimal assistance when they are in familiar situations. Orientation is improving, although they may still become confused, especially in unfamiliar surroundings. Attention is improving, as is memory, although they will continue to need support to recall new information, including minimal assistance to use memory aids. They demonstrate poor problem solving and self-awareness, often overestimating their abilities. They can also continue to have behavioral issues, becoming uncooperative with their caregivers and demonstrating poor social interactions with inappropriate behaviors..

Level VIII

Purposeful and appropriate; standby assistance for routine daily living skills. At this stage, people are able to initiate and complete routine tasks in familiar environments with only supervision, but they need assistance to solve problems when they arise. They are increasingly aware of their limitations, although they may still over- or underestimate their abilities. Their memory is improving, although they still need assistance, such as from external devices, to recall information. They are able to use aids with supervision. They are able to learn new skills and tasks, especially in consistent and predictable environments. Their social interaction is improving as well, and they have fewer inappropriate responses, although these can still occur. They may also demonstrate shallow irritability (i.e., when they become easily frustrated or annoyed).

Level IX

Purposeful and appropriate; standby assistance on request for daily living skills. At this stage, people are increasingly independent, needing occasional assistance with unfamiliar tasks or to avoid problems, especially with more complex tasks or in more complicated or dynamic environments. Their ability to complete familiar routines with ADLs, instrumental activities of daily living (IADLs), work, and leisure is vastly improved, and they can be without supervision much of the time. They may still need to use memory devices and may need occasional help with setting them up. They may still have shallow irritability but are better able to appreciate others’ feelings. They can monitor their social behavior better, with only occasional assistance.

Level X

Purposeful and appropriate; modified independent. At this stage, people are largely independent and can live alone. They have a good understanding of their limitations and can compensate for them, including with memory devices set up independently, although they may need extra time to problem solve or complete activities. They may also become easily fatigued. Their social behavior is appropriate, and they display fewer episodes of shallow irritability unless they are ill, stressed, or tired.