Bushnik , PhD, Santa Clara Valley Medical Center at
Citation Bushnik, T. (2000).
The Level of Cognitive Functioning Scale. The Center for
Outcome Measurement in Brain Injury. http://www.tbims.org/
combi/lcfs ( accessed
This citation is for the COMBI web material. Dr. Bushnik is
not the scale author for the LCFS.
- No response
appears to be in a deep sleep and is completely unresponsive
to external stimuli.
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.
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. Simple commands may be
followed in an inconsistent, delayed manner, such as closing
eyes, squeezing or extending an extremity. Once external stimulus
is removed, the patient may lie quietly. A vague awareness
of self and body may be shown by responses to discomfort produced
by pulling at nasogastric tube or catheter or resisting restraints.
Bias may be shown by responding to some persons (especially
family/friends) but not to others.
is in a heightened state of activity with severely decreased
ability to process information. Patient is detached from the
present and responds primarily to his/her own internal confusion.
Behavior is frequently bizarre and non-purposeful relative
to immediate environment. Patient may cry out or scream out
of proportion to stimuli even after removal, may show aggressive
behavior, attempt to remove restraints or tubes or crawl out
of bed in a purposeful manner. However there is no ability
to discriminate among persons or objects and no ability to
cooperate directly with treatment effort. Verbalization is
frequently incoherent and/or inappropriate to the environment.
Confabulation may be present; euphoria or hostility may be
present. Thus gross attention is very short and selective
attention is often non-existent. Being unaware of present
events, patient lacks short term recall and may be reacting
to past events. Patient is unable to perform self care (feeding,
dressing) without maximum assistance. If not disabled physically,
motor activities as in sitting, reaching and ambulating, may
be performed but as part of the agitated state and not as
a purposeful act or on request necessarily.
- Confused, inappropriate - non-agitated
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. Agitated
behavior may be present, 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. Patient 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, patient 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. Memory is severely impaired, with confusion
of past and present in reaction to ongoing activity. Patient
lacks initiation of functional tasks and often shows inappropriate
use of objects without external direction. When structured,
patient may be able to perform previously learned tasks, but
is unable to learn new information. Response 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/she
may wander off either randomly or with vague intention of
shows goal directed behavior, but is dependent on external
input for direction. Response to discomfort is appropriate
and unpleasant stimuli (as nasogastric tube) can be tolerated
when need is explained. Simple directions are followed consistently
and carryover for tasks that have been relearned (as self
care) is shown. Patient is at least supervised with old learning;
unable to maximally assist for new learning with little or
no carryover. Responses may be incorrect due to memory problems,
but they are appropriate to the situation. They may be delayed
and decreased ability to process information with little or
no anticipation or prediction of events is shown. Past memories
show more depth and detail than recent memory. The patient
may show beginning immediate awareness of personal situation
by realizing he/she doesn't know an answer. Patient no longer
wanders and is inconsistently oriented to time and place.
Selective attention to tasks may be impaired especially with
difficult tasks and in unstructured settings, but is now functional
for common daily activities (30 min with structure). At least
a vague recognition of some staff is shown and increased awareness
of self, family, and basic needs (as food), again in an appropriate
manner as in contrast to Level V, is demonstrated.
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 activities. Increased awareness of self, body, family,
foods, people, and interaction in the environment is shown.
Patient has superficial awareness of, but lacks insight into
his/her condition, demonstrates decreased judgement and problem
solving, and lacks realistic planning for personal future.
Carryover for new learning is shown, but at a decreased rate.
At least minimal supervision for learning and for safety purposes
is required. Patient is independent in self-care activities
and supervised in home and community skills for safety. With
structure he/she is able to initiate tasks in social and recreational
activities in which he/she now has interest. Patient's judgement
remains impaired; such that he/she is unable to drive a car.
Pre-vocational or avocational evaluation and counseling may
- Purposeful and appropriate
is alert and oriented, is able to recall and integrate past
and recent events and is aware of and responsive to his/her
culture. Carryover for new learning is shown if it is acceptable
to the patient and his/her life role, and needs no supervision
once activities are learned. Within physical capabilities,
patient is independent in home and community skills, including
driving. Vocational rehabilitation, to determine ability to
return as a contributor to society (perhaps in a new capacity),
is indicated. A decreased ability, relative to premorbid abilities,
reasoning, tolerance for stress, judgement in emergencies
or unusual circumstances, may continue to be shown. Social,
emotional and intellectual capacities may continue to be at
a decreased level, but are functional for society.