Levels of Cognitive Functioning

Level I – No Response

Patient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.

Level II – Generalized Response

Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Responses are limited in nature and are often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization. Often, the earliest response is to deep pain. Responses are likely to be delayed.

Level III – Localized Response

Patient reacts specifically, but inconsistently, to stimuli. Responses are directly related to the type of stimulus presented as in turning head toward a sound or focusing on an object presented. The patient may withdraw an extremity and/or vocalize when presented with a painful stimulus. He may follow simple commands in an inconsistent, delayed manner such as closing his eyes, squeezing or extending an extremity. Once external stimuli is removed, he may lie quietly. He may also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube or catheter or resisting restraints. He may show a bias toward responding to some persons (especially family, friends) but not to others.

Level IV – Confused/Agitated

Patient is in a heightened state of activity with severely decreased ability to process information. He is detached from the present and responds primarily to his own internal confusion. Behavior is frequently bizarre and non-purposeful relative to his immediate environment. He may cry out or scream out of proportion to stimuli even after removal, show aggressive behavior, attempt to remove restraints or tubes, or crawl out of bed in a purposeful manner. He does not, however, discriminate among persons or objects and is unable to cooperate directly with treatment efforts. Verbalization is frequently incoherent and/or inappropriate to the environment. Confabulation may be present; he may be euphoric or hostile. Thus, gross attention to environment is very short and selective attention is often nonexistent.

Being unaware of present events, patient lacks short-term recall and may be reacting to past events. He is unable to perform self-care (feeding, dressing) without maximum assistance. If not disabled physically, he may perform motor activities such as sitting, reaching, and ambulating, but as part of his agitated state and not as a purposeful act or on request, necessarily.

Level V – Confused, Inappropriate Non-Agitated

Patient appears alert and is able to respond to simple commands fairly consistently; however, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or, at best, fragmented toward any desired goal. He may show agitated behavior, but not on an internal basis (as in Level IV), but rather as a result of external stimuli, and usually out of proportion to the stimulus. He has gross attention to the environment, but is highly distractable and lacks ability to focus attention to a specific task without frequent re-direction back to it. With structure, he may be able to converse on a social-automatic level for short periods of time.

Verbalization is often inappropriate; confabulation may be triggered by present events. His memory is severely impaired, with confusion of past and present in his reaction to ongoing activity. Patient lacks initiation of functional tasks and often shows inappropriate use of objects without external direction. He may be able to perform previously-learned tasks when structured for him, but is unable to learn new information. He responds best to self, body, comfort, and, often, family members. The patient can usually perform self-care activities, with assistance, and may accomplish feeding with maximum supervision. Management on the ward is often a problem if the patient is physically mobile, as he may wander off, either randomly or with vague intentions of “going home”.

Level VI – Confused, Appropriate

Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and he is able to tolerate unpleasant stimuli (as NG tube) when need is explained. He follows simple directions consistently and shows carry-over for tasks he has relearned (as self-care). He is at least supervised with old learning; unable to maximally be assisted for new learning with little or no carry-over. Responses may be incorrect due to memory problem, but they are appropriate to the situation. They may be delayed to immediate and he shows decreased ability to process information with little or no anticipation or prediction of events. Past memories show more depth and detail than recent memory.

The patient may show beginning immediate awareness of situation by realizing he doesn’t know an answer. He no longer wanders and is inconsistently oriented to time and place. Selective attention to task may be impaired, especially with difficult tasks and in unstructured settings, but is now functional for common daily activities (30 min. with structure). He may show a vague recognition of some staff, has increased awareness of self, family and basic needs (as food), again, in an appropriate manner as in contrast to Level V.

Level VII – Automatic, Appropriate

Patient appears appropriate and oriented within hospital and home settings, goes through daily routine automatically, but frequently robot-like, with minimal-to-absent confusion, but has shallow recall of what he has been doing. He shows increased awareness of self, body, family, foods, people, and interaction in the environment. He has superficial awareness of, but lacks insight into, his condition, decreased judgement and problem-solving and lacks realistic planning for his future. He shows carry-over for new learning, but at a decreased rate. He requires at least minimal supervision for learning and for safety purposes. He is independent in self-care activities and supervised in home and community skills for safety. With structure, he is able to initiate tasks as social or recreational activities in which he now has interest. His judgement remains impaired; such that he is unable to drive a car. Prevocational or avocational evaluation and counseling may be indicated.

Level VIII – Purposeful, Appropriate

Patient is alert and oriented, is able to recall and integrate past and recent events, and is aware of, and responsive to, his culture. He shows carry-over for new learning if acceptable to him and his life role, and needs no supervision once activities are learned. Within his physical capabilities, he is independent in home and community skills, including driving. Vocational rehabilitation, to determine ability to return as contributor to society (perhaps in a new capacity) is indicated. He may continue to show a decreased ability, relative to premorbid abilities, in abstract reasoning, tolerance for stress, judgement in emergencies or unusual circumstances. His social, emotional, and intellectual capacities may continue to be at a decreased level for him, but functional in society.

Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.