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Managing Cognitive Effects of TBI

Managing Cognitive Effects

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.

Tracy, what do you mean by cognitive effects?

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.

So what kind of cognitive problems are there?

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.
So, we have to just sit around and wait for Dad’s brain to heal?

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.

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.

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.

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.

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.

That sounds like a good way to stay organized.

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

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.

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

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.

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.

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.

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

What kind of communication problems is Tom having?

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

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.

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

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.

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

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?

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.

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…

When and why.

I knew that.

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.

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

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

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.

Not Speaking Clearly

What you might see:

  • Slurred speech 
  • Speaking too loudly or softly 
  • Speaking too rapidly

How you can help:

  • Tell your family member that you did not understand what he or she said. Ask him or her to say it again more slowly.
  • Use a consistent cue or gesture to let him or her know you did not understand. For example, cup your hand over your ear as a reminder to speak louder.
  • Allow time for your service member/veteran to express him or herself.

Starting Conversation

What you might see:

  • Unable to start or is slow to start conversations 
  • Long pauses 
  • Problems explaining what he or she means 
  • Does not respond to another’s questions or comments

How you can help:

  • Help your service member/veteran start a conversation by asking a leading question such as, “What do you think about ...?”
  • Encourage your service member/veteran to talk about topics of interest or familiar topics.
  • Ask open-ended questions (e.g., questions that cannot be answered with a “yes” or “no”), such as, “Tell me more about your day.”
  • Give your service member/veteran with TBI your full attention. 
  • Give your service member/veteran time to organize his or her thoughts.
  • Use redirection, if necessary (e.g., “So what do you think about....?”)
  • Reinforce all efforts to start a conversation. Show that you value what your service member/veteran has to contribute to conversations.

Word Finding

What you might see:

  • Problems finding the right word to describe what he or she is trying to say

How you can help:

  • Give your family member time to locate the word he or she is looking for.
  • If he or she still cannot locate the word after some time, guess at what he or she might mean. Or ask him or her to write it down.
  • Try to be patient. It can be very frustrating for your service member/veteran when he or she knows what he or she wants to say but cannot locate the right word or phrase.
  • Encourage him or her to use another word that is close in meaning.
  • Suggest that he or she use many words (or a description) instead of using a single word. (This is called circumlocution, a strategy speech language pathologists will often teach.)

Following Conversation

What you might see:

  • Difficulty paying attention to what is said
  • Misinterpreting what is said
  • Being “off topic” compared to the rest of the people in the conversation

How you can help:

  • Get your service member/veteran’s attention before speaking. 
  • Be clear and to the point. Keep it simple.
  • Reduce distractions. 
  • Every so often, stop and ask your family member to restate what he or she heard to ensure understanding.
  • Reduce your rate of speech and pause frequently to allow the person time to process and respond.
  • Avoid abrupt topic changes. 
  • In group conversations, help set a slower pace of conversation.

Reading Comprehension

What you might see:

  • Problems understanding what is read
  • Trouble stating the main idea or main point

How you can help:

  • Read with your service member/veteran. 
  • Review the reading material, using the 5W strategy – Who, What, Where, When, Why:
    • Who are the characters?
    • What happened to the characters in the book? What did they do about it?
    • Where did it happen? 
    • When did it happen? 
    • Why did it happen?
  • The 5W’s should be related, that is, they should refer to the same characters or portion of the story.
  • Your service member/veteran can write out important information or say it out loud; this uses other senses to increase comprehension.
  • Emphasize important information in the text.


Dysarthia means having a hard time using the muscles needed to form words and produce sounds.

What you might see:

  • Speech is often slow, slurred, and garbled
  • Problems with intonation or inflection

How you can help:

  • The speech language pathologist will prescribe exercises to improve the muscles used in speaking. Over time, these exercises will make your family member’s speech more clear. Help him or her to do these exercises properly and regularly.
  • Allow ample time for your service member/veteran to express him or herself.
  • Encourage him or her to take time to speak. 
  • Inform those around your service member/veteran about the diagnosis so they too allow the person time to express him or herself.


What you might see:

  • Talking non-stop 
  • Not allowing the listener a turn to speak 
  • Frequent interruptions
  • Inability to adjust communication style for the situation
  • Bringing up the same topic over and over again (perseveration)

How you can help:

  • Politely interrupt and ask for a chance to speak. Tell your service member/veteran you would like to say something.
  • Ask your service member/veteran to please make it brief. 
  • Develop a hand signal, which indicates to the service member/veteran that he or she may be monopolizing the conversation.
  • Gently alert him or her to the fact that the topic change was too abrupt or that he or she has interrupted and will be given a chance to say his or her piece in a moment.
  • Use positive reinforcement for all attempts at listening rather than talking.
  • Your service member/veteran may be interrupting because he or she is “lost” in the conversation. Encourage him or her to let you know if he or she doesn’t understand what is being said.

Topic Selection

What you might see:

  • Problems finding good topics for conversation 
  • Problems keeping up when topics change 
  • Introducing a new topic abruptly 
  • Problems staying on topic

How you can help:

  • Pick topics that your service member/veteran enjoys. Ask about his or her interests and opinions.
  • Clarify new topics as they come up.
  • Ask how his or her comment relates to the topic: “How does the price of gas relate to what you ate for lunch?”
  • Tell your service member/veteran you are confused or getting lost in the conversation.
  • Gently but firmly alert your service member/veteran if he or she is bringing up a topic that may be offensive to others.


What you might see:

  • Problems expressing thoughts in writing 
  • Problems getting started writing 
  • Writing the same words or phrase over and over (perseveration)

How you can help:

  • Practice writing with your service member/veteran. For example, write letters to friends or relatives.
  • Make a list of openings (i.e., Dear, Hello, Hi, etc.) and closings (i.e., Thank You, Sincerely, Yours Truly) and the reasons for selecting them.
  • Suggest saying words out loud before writing them. 
  • Suggest reading what is written to make sure it makes sense.

Nonverbal Communication

What you might see:

  • Having a hard time understanding common nonverbal cues (e.g., facial expressions, hand gestures)
  • Standing too close or too far from those he or she is speaking to 
  • Uncomfortable number/type of physical contacts 
  • Body language that doesn’t “match” what is said 
  • Facial expressions that don’t “match” what is said
  • Poor eye contact
  • Staring at others during conversation

How you can help:

  • Politely ask your service member/veteran to stand closer or further away.
  • Explain the behavior is making you feel uncomfortable.
  • Tell your service member/veteran you are confused by the difference in body language and spoken message. Briefly explain what you saw and heard.
  • Ask him or her to stop any distracting motions.
  • Role play the right way to behave in a particular setting. Work with the health care team to practice appropriate behavior. This will help decrease behavior that causes problems.
  • Talk to your family member about how to act in certain situations, before he or she is in those situations.
  • Give feedback on the right amount of eye contact to keep with another person. Praise all improvements.
  • Decide on a signal to indicate problematic behavior.
Related Information:
Cognitive Effects
Neuropsychological Evaluation
Common Cognitive Effects
Memory Compensation
Communication Effects
Behavioral Effects
Emotional Effects
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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