COMBI >> Scales >> Level of Cognitive Functioning Scale >> Syllabus


Tamara Bushnik , PhD, Santa Clara Valley Medical Center at

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Bushnik, T. (2000). The Level of Cognitive Functioning Scale. The Center for Outcome Measurement in Brain Injury.
combi/lcfs ( accessed ).*

*Note: This citation is for the COMBI web material. Dr. Bushnik is not the scale author for the LCFS.





LCFS Syllabus




I - No response

Patient appears to be in a deep sleep and is completely unresponsive to external stimuli.

II - Generalized

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.

III - Localized

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. 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.

IV - Confused-agitated

Patient 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.

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. 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 "going home".

VI - Confused-appropriate

Patient 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.

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 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 be indicated.

VIII - Purposeful and appropriate

Patient 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.



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