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Rancho Los Amigos Scale

Level 4

When someone is level 4, they have a poor memory and are often confused. They may also be agitated, meaning they may cry, yell, scream, and have uncontrolled reactions. This can be frightening for the family.

Remember that this level is a sign that the brain is healing. It’s not a change in their personality.

During level 4, they:

  • will shift from not reacting much to reacting a lot
  • may be violent (hit)
  • may be very confused and scared
  • may need restraints to keep them safe
  • may not talk clearly or make sense when they talk
  • won’t remember new information well
  • may “make up” stories to fill in gaps of information (called confabulation)
  • only remember what happened before the brain injury
  • won’t be able to pay attention for very long
  • need a lot of help with self-care (like combing their hair)

How to help during level 4

You can do the following things to help your loved one during level 4:

  • Remind them what day and time it is, and where they are. If they argue or don’t believe you, don’t argue back. Try talking about something else.
  • Have only 1 or 2 visitors at a time.
  • Limit the amount of things happening in the room at any one time. For example, don’t talk to them, play the radio, feed them, stroke their arm, and visit with others all at the same time. Too many things happening at once will make them more confused.
  • If they’re not talking yet, look for another way to get them to respond. This could be having them nod or shake their head, or tap their finger to show “yes” or “no”. Encourage them to respond the same way each time to help them remember.
  • When they’re agitated, don’t leave the room or ignore them. Having family with them and being comforted will help calm them. You can try calming them by touching their face, washing their face or body with warm water, or playing soft music.
  • Be patient. They usually won’t know what they’re doing or saying. It’s very normal to get impatient and frustrated. If they swear at you or get agitated and act out, don’t take it personally. Remember, the way they act or respond during level 4 is related to the brain injury.

Caring for yourself during level 4 and beyond

By this stage, you and your family may feel tired and have gone through many feelings. You will have “highs” and “lows”. You may feel “low” from the fear of losing your loved one to feeling “high” from seeing them start to recover.

By this stage, you and your family usually know that your loved one may live with some disability from the brain injury. This may make you feel depressed or afraid. It’s very normal to feel this way.

Counselling can help you and your family cope and adjust to these changes. You may also feel better if you talk about your feelings with a member of the healthcare team.​

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