Rancho Los Amigos Levels of Cognitive Functioning
I would like to begin with a basic overview of what we call the Rancho Los Amigos Levels of Cognitive Functioning. Those of you practicing in occupational therapy, particularly brain injury, have probably heard of the Rancho scales. Dr. Chris Hagen, one of the developers of the Rancho scales, as he transitioned from treating inpatients to doing more outpatient and community-based work, found the original eight levels of the Rancho scale were somewhat misleading. It assumed that once you reached level VII or level VIII, you were ready to resume participation in all the roles that you engaged in before your injury. This is problematic. Even though we do a very good job keeping people alive and moving them through the Rancho scales, we have learned through research, that the outcomes, particularly for moderate to severe traumatic brain injury, tend to be very poor. This group has very high unemployment, are over-represented in the courts, high divorce rates, and high rates of depression.
When we talk about participation, the foundation of occupational therapy, we are not just getting people to move and remember things better, but we are experts in community participation, resuming those occupations that they can do successfully and satisfactorily. Usually when someone reaches level VII/level VIII, they are discharged from an inpatient setting. Levels VIII, IX, and X can continue to have residual deficits that impact functional performance.
Defining Executive Cognitive Functions
There are lots of different definitions out there and most have been around for some time. We generally associate executive functions with frontal lobe damage and/or frontal lobe functioning . You can think of executive functions as the executive of a large corporation, a person who is responsible for overseeing the functions of the other levels of the business. We see are terms like selecting, programming, and regulating; all of those things that really define adult behavior. Myelination of the frontal lobes is thought to happen in your mid-20s. By this age, many people have made life choices such as: college, careers, marriage, etc. When we talk about efficiently functioning executive functions, we are talking about those things that make you a good college student, a good spouse, parent, worker, and roles that are critical to adult functioning. Metacognition enables a person to engage successfully in independent, purposive, self-serving behavior (Lezak, 1995). It really involves acting upon the environment.
One of the things that I have learned from working in brain injury rehabilitation, throughout the different settings of practice, is that there are challenges all along the way. When people reach the community, they often appear worse. They may appear fine in a structured environment, but in their natural environments deficits become present.
