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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.

Depression

Many people with TBI become depressed. This depression comes from both the physical changes in the brain due to the injury and the emotional reactions to it.

It is sometimes hard to tell the difference between symptoms of depression and effects of the TBI. For example, depressed people and people with TBI may have:

  • low activity level 
  • sleep problems
  • difficulty controlling emotions
  • lack of initiation

Men and women often have different symptoms of depression. They also have different ways of coping with the symptoms.

Men often report symptoms of:

  • fatigue 
  • irritability/anger 
  • loss of interest in pleasurable activities 
  • sleep disturbances

Men are more likely than women to use alcohol or drugs when they are depressed. They may engage in reckless, risky behavior. Men also tend to avoid talking about their feelings of depression with family or friends.

Women are more likely to talk about depressive symptoms to others. They often report feelings of:

  • persistent sadness 
  • anxiety 
  • excessive crying 
  • feelings of guilt/worthlessness 
  • decreased energy
  • increased appetite 
  • sleep problems 
  • weight gain

In severe cases, both men and women may experience thoughts of suicide.

If you suspect that your family member is depressed, ask your health care team to evaluate his or her mental health. This is very important.

Depression can be treated with counseling and medication. If the depression is affecting the family, marriage and/or family therapy can help.

What you might see:

  • Persistent sad, anxious, or “empty” feelings 
  • Feelings of hopelessness and/or pessimism 
  • Feelings of guilt, worthlessness, and/or helplessness 
  • Irritability, anger, restlessness 
  • Loss of interest in activities or hobbies once pleasurable, including sex 
  • Fatigue and decreased energy
  • Problems concentrating, remembering details, and making decisions
  • Insomnia, early morning wakefulness, or excessive sleeping
  • Overeating, or appetite loss
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
  • Less attention paid to grooming and personal appearance
  • Thoughts of suicide, suicide attempts

How you can help:

  • Offer emotional support, understanding, patience, and encouragement. Remind your family member that depression usually fades with time and treatment.
  • Talk to your family member and listen carefully.
  • Acknowledge feelings, point out realities, and offer hope.
  • Get your family member involved in activities outside the house (e.g., walks, shopping, movies, church services, volunteering). If he or she declines, keep making gentle suggestions but don’t insist.

Remember, depression is common as a person struggles to adjust to the temporary or lasting effects of TBI. Being depressed is not a sign of weakness. It is not anyone’s fault. Help is available...do not wait to call someone if you think your family member needs help.

Know the signs of a person thinking of suicide: 

  • making a will 
  • taking steps to get affairs in order 
  • giving away personal possessions
  • sudden requests to visit friends or other service members/veterans
  • purchasing a gun or stockpiling medications 
  • a sudden and significant decline or improvement in mood 
  • writing a suicide note

Call 911 immediately or bring your family member to the closest hospital if you have any suspicion about suicide. It is perfectly fine to directly ask the person if he or she has been having suicidal thoughts. If yes, ask if he or she has a specific plan in mind. Having a plan for killing oneself is a serious sign to get help quickly.

Always take a person’s threats of suicide seriously. Get immediate help. Call the health care team or an emergency hotline (DoD/VA: 1-800-273-TALK) right away. Make sure to remove or secure any available firearms.

Anxiety

People with TBI often become anxious. Anxiety sometimes goes hand in hand with depression.

What you might see:

  • Constant physical tension
  • Excessive worry, racing thoughts
  • Feeling jumpy, irritable, restless
  • Racing heart, dry mouth, excess sweating, shakiness, or feeling short of breath
  • Feeling panic or having a sense that something bad is going to happen

How you can help:

  • Work with your family member to recognize problems that he or she may be worried about. Use problem-solving techniques to address them. This can help put the issue into perspective.
  • Suggest that your service member/veteran write things down or keep a journal. Sometimes this alone can be calming and can slow down racing and nervous thoughts.
  • Use redirection (i.e., try to change the topic or focus of interest to something else).
  • Ask your family member to talk with the doctor about medications for anxiety. Counseling may also help.
  • The health care team may suggest other ways to reduce anxiety. These could include relaxation training, controlled breathing, and other coping strategies. If they do, practice these strategies with your family member.

Mood Swings

It can be frustrating and embarrassing when you can’t control your emotions. It can make it hard to participate in social situations.

What you might see:

  • Laughing one minute, and feeling sad or crying the next
  • An emotional response that does not “fit” the situation (i.e., crying when others are laughing, laughing when receiving news about the death of a loved one)
  • Frequent, unexpected shows of emotion

How you can help:

  • Reassure your family member that you understand that his or her display of emotion may not match the situation. Be nonjudgmental.
  • Help family and friends understand sudden shifts in your family member’s mood.
  • Distract your family member. Use redirection (i.e., try to change the topic or focus of interest to something else).
  • If the mood swings are interfering with your family member’s everyday life, ask him/her to talk with the doctor. Medications may be helpful in managing mood swings.

Self-Esteem

A person’s view of him or herself can be negatively affected by TBI. Feelings of low self-esteem go hand in hand with depression.

What you might see:

  • Negative self statements: “I am worthless,” “I’ll never be normal again,” “How can you love me like this?”
  • Less interest in personal appearance
  • Social withdrawal

How you can help:

  • Encourage your family member to express his or her feelings. Try to redirect the person to more positive thoughts.
  • Encourage your family member to spend time with others. Encourage him or her to take part in independent activities.
  • Help your family member to set realistic, attainable goals. Help him or her to choose activities that he or she can successfully complete.
Related Information:
Cognitive Effects
Neuropsychological Evaluation
Common Cognitive Effects
Memory Compensation
Communication Effects
Behavioral Effects
Emotional Effects
Glossary
Frequently Asked Questions
"I so wish that at the beginning I had had someone like the people I’ve met here at Fisher House, who are already two years post-injury. I wish I would have had some- body like that come up to me and just put their arms around me and say, You know what? Any question you need to ask, just ask it." -  Meredith H.

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