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Managing Cognitive Effects of TBI

Managing Cognitive Effects

Tracy
Hi everybody. Welcome back. I hope you each had a wonderful week. So how are you all doing?

Good. That’s good. Now remember, last week we talked about the physical effects of TBI. Today we’re going to talk about some of the other effects that can result from a brain injury. Let’s start with the cognitive effects you might have noticed in your loved one.

Travis
Tracy, what do you mean by cognitive effects?

Tracy
Travis, cognitive effects are the changes in the way the brain thinks. After a TBI, thinking may be different. It may be harder than it used to be. Now in most cases, cognitive problems will improve over time through rehabilitation, and of course the natural healing of the brain itself. But… but keep in mind that cognitive recovery often takes longer than physical recovery, so… so you really do have to try to be patient.

The neuropsychologist, the OT, the speech pathologist they’re all the team members who specialize in treating those cognitive problems. The neuropsychologist will do some testing to see how well your loved one’s brain is working and if there are any cognitive challenges.

Megan
So what kind of cognitive problems are there?

Tracy
You know some of the most common cognitive effects are things like confusion, slower thinking, problems with paying attention. Many TBI patients have memory issues, challenges with planning, organization, decision-making, problem solving, you know things like that.
 
Travis
So, we have to just sit around and wait for Dad’s brain to heal?

Tracy
Well you know to some extent. It will heal on it’s own but you know, Travis, there are things that you and your family can do to help.

Julie
That’s right, Travis. When Sam first woke up he had a hard time understanding what we were saying, and he was confused about what had happened to him. So the doctors told me and Carl to speak slowly and to frequently remind Sam about the things that happened.

Carl
They also said that we should break down complex tasks and activities into smaller steps. We learned to give Sam extra time to respond to questions and to comprehend and learn new information.  Another thing they told us was to avoid situations that are too stimulating for Sam, because his brain couldn’t handle the sensory overload.

Tracy
Yeah. Those are good suggestions. Along that same line, now if your Dad has problems with memory, you can help him use memory aids on a regular basis. You can encourage him to write down tasks on a calendar for instance or a notebook, and then check those tasks when they’re done. And in some cases, you may have to write down things for him.

Julie
Another thing that really helps Sam with his memory, especially his short-term memory, is his PDA. It’s set to remind him about his appointments, any plans he makes, and even when to take his medicine.

Michelle
That sounds like a good way to stay organized.

Julie
Exactly. Sam has had to relearn all of his organizational skills, and the PDA really seems to help.

Michelle
I’ll ask Tom’s OT about getting one tomorrow. She’s been great about giving Travis, Emily and me tips on helping Tom get organized…things like using notes and cue cards as reminders, and keeping Tom’s things in the same place so he can find them.

Travis
Well that’s pretty easy in the hospital room, but it’ll be harder when he comes home.

Tracy
That’s a good point, Travis. It may also be harder to get rid of the distractions, things like… well the TV, the stereo, when your Dad gets home, but you know it’s important to help him concentrate on specific tasks. That will make a difference.

Michelle
One thing that I’ve noticed is that Tom is having trouble right now making decisions - - even small ones like what to eat for dinner.

Tracy
Yeah, that’s pretty common, Michelle. Making decisions, problem solving they can be very challenging after a TBI. But you can help Tom by giving him plenty of time to make a decision. And it will be helpful if you talk him through all those possible options. When it’s possible, you can limit the number of choices... maybe keeping them to 2 or 3 at best. Too many choices can just obviously be overwhelming.

So those are just a few of the cognitive problems that your loved one may have as they get better. You’ll find information on more cognitive challenges and what you can do to help in your Guide for Caregivers.

Michelle
I also noticed some great tips in the Guide about how to help Tom with his communication problems. That’s been really helpful.

Megan
What kind of communication problems is Tom having?

Michelle
Well, even though he’s speaking more, he seems to have a problem finding the words he needs to express himself.

Tracy
That’s not unusual Michelle. And, sometimes people with TBI have a hard time actually forming the words or speaking clearly. They also may have a hard time hearing and understanding when people talk to them.

Megan
So what things have you tried to help Tom with his communication?

Michelle
I think the biggest thing is letting him know when we can’t understand him. I ask him to say things again, and to talk slower sometimes.

Travis
And the speech therapist told me to do this to let Dad know that I don’t know understand him sometimes.

Tracy
What you’re doing is you’re giving your Dad a visual cue that you don’t understand him. And those… Those are really good suggestions. So Julie and Carl, have you run into any communication problems with Sam?

Carl
Well, he’s definitely gotten better, but he still has a hard time starting or following a conversation. We’ve learned to be encouraging, and to help direct him by asking sort of open-ended questions.  That helps him.

Julie
He’s also having some problems understanding things that he reads. So to help him with that, we’ve been reading with him, and using something called the 5W strategy, so that helps him comprehend what he’s read. The 5W’s are who, what, where…

Carl
When and why.

Julie
I knew that.

Tracy
Well that’s great, you guys. You know there’s information on how to use the 5W’s and lots of other tips on how to help with communication, and reading and writing in the Guide for Caregivers.

Okay, before we move on there’s another area that I’d like to touch on, and that’s how TBI can affect your loved one’s emotions, their behavior. You may notice changes in the way your family member acts. They may be angry, might be aggressive behavior, impulsive actions, things like that.

Travis
My Dad’s like… frustrated a lot of the time. He seems really moody. And just some of the things he says seem weird.

Julie
I understand, Travis. Sam is like that too. Sometimes he seems really anxious and depressed. We’ve been trying to help him with that.

Tracy
It’s important that you offer a lot of emotional support, a lot of encouragement. Anxiety and depression are very common in people with TBI. You have to remember being depressed isn’t a sign of weakness. It’s not anyone’s fault. Just remember that help is available so don’t wait to call someone. If you think your family member needs help, get on it right away. There’s… there’s more information about how to help you loved one and the behavioral and emotional effects in your Guide for Caregivers.

Okay so let’s take a short break and when we get back we’ll talk more about your job as a caregiver. So help yourselves to some coffee if you’d like.

Confusion

Most people with severe TBI experience some confusion after their injury. It is expected.

Sometimes confusion only lasts minutes. Other times, it can last days or even weeks.

Keeping your family member safe, reminding him or her about what’s going on, and offering reassurance are important during this stage of recovery.

What you might see:

  • Disorientation (not sure of where he or she is, time of day, what has happened)
  • Seems in a fog, staring blankly
  • Confusing times/tasks in schedule of activities
  • Confusing past and present events
  • Making up convincing stories to fill memory gaps. This is called confabulation.

How you can help:

  • Keep your family member oriented. Put calendars, clocks, family pictures, and/or a sign about where he or she is and what has happened, in his or her room. A list of health care team members and what each one does may also be useful.
  • Use a notebook to plan for and log events. Have your family member refer to it for details of daily events.
  • Frequently remind your service member/veteran of correct details of past and present events.
  • Limit changes and provide structure in a daily routine.

Speed of Processing

Many people with TBI complain that their thinking and processing of information is much slower than it used to be.

This problem improves over time. It can be frustrating in today’s fast- paced world.

Slowed speed of processing can add to confusion.

What you might see:

  • Taking longer to answer questions
  • Taking longer to understand things that were easily understood before
  • Taking a long time to react and respond

How you can help:

  • Slow down and simplify information.
  • Break complex tasks and activities down into smaller steps.
  • Allow extra time to respond to questions and to comprehend and learn new information.
  • Avoid situations that are overstimulating (e.g., noise, crowds).
  • Suggest a different activity or topic of conversation to help the person remain on task.
  • Encourage your service member/veteran to ask others to slow down and repeat information.

Attention Problems

The ability to focus, to pay attention for a long time, and to do more than one thing at a time is controlled by the brain.

TBI can and often does affect all forms of attention.

Attention is important because paying attention is the first step to learning and remembering.

It is not uncommon for a person with a severe TBI to only be able to attend for a few minutes at a time in the beginning.

What you might see:

  • Short attention span, sometimes only minutes in duration 
  • Easily distracted 
  • Difficulty in attending to one or more things at a time 
  • Inability to shift attention from one task or person to the next 
  • Difficulty completing tasks

How you can help:

  • Focus on one task at a time.
  • Be sure you have your service member/veteran’s attention before beginning a discussion or task.
  • Reduce clutter at home and in the work environment. 
  • Perform tasks in a quiet environment.
  • Remove distractions and noises that you don’t need. As best as possible, use timers (watches, PDAs, or other devices) and checklists in the calendar/memory notebook to help with completion of tasks.
  • Refocus attention to the task at hand.
  • Expect a short attention span. Schedule rest breaks and/or stop an activity when you notice drifting attention.
  • When signs of distraction arise, insert a rest break (“Let’s do this for another 5 minutes and then take a 15 minute break.”).
  • Present verbal or visual information in limited amounts.

Memory

Memory problems happen often after a TBI. Past memories or long-term memory is nearly always intact. Recent memory, called short-term memory, is much more often affected.

Short-term memory often gets worse as fatigue increases.

Short-term memory usually improves over time.

Memory compensation means learning to use memory tools, such as a calendar, planner, organizer, or memory notebook.

Signs with instructions, lists, and notes are other effective memory compensation tools.

Ask the health care team about which memory tools would be helpful for your family member.

These tools may also help you remember everything you need to do!

What you might see:

  • Can’t remember information from day to day about people, conversations, places, events, appointments, dates, and telephone numbers
  • Keys, wallet, etc. are frequently lost or misplaced 
  • Repeating questions or the same story over and over again 
  • Can’t learn new information and use it in everyday life

How you can help:

  • Get the person’s attention when you are trying to teach, do, or discuss something.
  • Break new information down into categories or “chunks.” List and review them in order.
  • Set up a routine of daily tasks and follow it.
  • Help your family member use memory aids on a regular basis. Write down tasks on a calendar or notebook. Check tasks off when done.
  • Explore use of “high tech” memory aids. Personal digital assistants (PDA), wristwatch alarms, and cell phones can remind your family member when to do a task, such as taking medication. Before spending money on these devices, ask the OT or speech pathologist whether your family member can learn to use the technology.
  • Buy a pillbox and label each compartment with the time and day that medication should be taken. Write the names of medications and when to take them into the calendar/memory notebook.
  • Keep personal and household items in the same place.
  • Try to pair new information with things the person is able to recall.
  • Provide verbal cues for recall and help fill in memory gaps.
  • Talk to your service member/ veteran about the activities and events of the day to help build memory.
  • Have your service member/veteran review plans for the following day. 
  • Learn and use a cueing system.
  • Present information in more than one way, including hearing, seeing, and doing. Each person has a different learning style. Ask the neuropsychologist how your family member learns best.
  • Role play in order to reinforce new learning.
     

Planning and Organization

Organization and planning skills are often affected by TBI.

These skills improve over time. The health care team will work with your family member to develop better organization and planning skills.

You may need to remind your family member again and again to use the skills he or she learns in therapy until they become a habit.

What you might see:

  • Problems organizing time to get things done 
  • Problems understanding which tools are needed to complete a task and getting them together 
  • Problems breaking down complex tasks into smaller steps 
  • Having a hard time getting ready for work, school, and appointments 
  • Being late for appointments and work or school 
  • Having a hard time starting a task 
  • Problems making plans and completing them 
  • Problems setting goals 
  • Trouble prioritizing 
  • Looking disorganized

How you can help:

  • Begin with small, realistic tasks.
  • Work with your family member to get organized at home. Keep a family calendar posted on a wall. Use reminder notes and cue cards.
  • Have a place for everything and keep everything in its place. In particular, keep your service member/veteran’s belongings in certain places.
  • Turn off the radio/TV or other distractions when tasks need to be done.
  • Use memory aids such as calendars and notebooks to plan, write down, and check off tasks when done.
  • Use a tote bag or backpack to organize needed items for the day.
  • Work with your service member/veteran to decide which information or activity has the highest priority.

Decision Making and Problem Solving

Making decisions and solving problems take a lot of thinking. Both can be hard for people with TBI.

Simple decision making and problem solving are easier than more complicated decision making and problem solving.

What you may see:

  • Taking a long time to make a decision
  • Making inappropriate and/or potentially harmful decisions
  • Problems reasoning
  • Responding impulsively to situations
  • Having a hard time recognizing problems
  • Slow to think of alternate solutions to problems
  • Tendency to be “concrete” in terms of problem solving, that is, difficulty making inferences
  • Taking things literally

How you can help:

  • Avoid having your service member/veteran make decisions when tired, hungry, or under stress.
  • Help your family member to weigh options and consequences of a decision.
  • Give your service member/veteran time to make a decision. Be patient and talk him or her through the possible options.
  • Limit the number of possible choices. Two or three choices is best. Too many are often overwhelming and can increase indecisiveness.
  • Avoid making last minute decisions. 
  • Practice identifying a problem and following through with evaluating the options.

 

Confabulation

Confabulation is a memory problem. It happens when a person with a brain injury makes up false memories.

These memories could be about past events that never happened. Or they could be memories of actual events that the person puts in the wrong time or place.

Sometimes these memories are very detailed and the person honestly believes the events happened.

Confabulation is the direct result of injury to the brain. It may go away on its own.

The health care team will work with your service member/veteran to reduce the effect by helping him or her to become more aware of it.

What you may see:

  • Making up convincing stories to fill memory gaps

How you can help:

  • Don’t accuse your family member of lying. 
  • Gently help your family member become aware that this memory is not accurate.
Related Information:
Cognitive Effects
Neuropsychological Evaluation
Common Cognitive Effects
Memory Compensation
Communication Effects
Behavioral Effects
Emotional Effects
Glossary
Frequently Asked Questions
"A really super thing for us in terms of communicating with the hospital staff—and the hospital already had this installed in the room—is a big dry erase board. Some people use it and some people don’t. We use it to make a list of all the things we want to talk about with the doctors. That way, if I’m not in the room when the doctors come by on their rotation, they’ve got the big list right there and they can see it clearly. That helps keep the communication going." -  Anna E.

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