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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.

Compensation Strategies

Compensation strategies are ways to help your family member manage cognitive changes. They build on the person’s strengths. At the same time, they make up for deficits in thinking caused by the TBI.

The OT, PT, and speech language pathologist are the health care team members who assess how well your family member is thinking. They will develop a cognitive rehabilitation program for your family member. Their assessments will pave the way for return to the community and will help decide if your family member can return to duty, work, or school.

Each person is unique. A compensation approach that works for one person might not work for another. What works during structured inpatient rehabilitation may not work in the same manner at home. Try approaches out with your service member/veteran with help from your health care team. If an approach does not work well, review it with a provider and try other strategies. Continue to use your health care team as experts in designing compensation approaches most likely to work for your service member/veteran with TBI.
 

Cueing

Cueing means to give a signal to begin a specific action. Cueing prompts your service member/veteran to stop and think before acting.

Cueing strategies are best learned from the therapists working with your service member/veteran. Attend therapy and observe how they cue the person. The goal of progressive cueing is to move your service member/veteran from having to be “told what to do” by you and rehabilitation team members to being able to independently cue, or remind, him or herself what he or she needs to do. Learning how to self-cue increases self-reliance. Consistency in approach increases the odds of success.

Try the following methods for cueing your service member/veteran with TBI:

  • Guide your service member/veteran by asking questions.
    • Ask questions that will help the person find a solution, such as “What could you do to help yourself next time?”
    • Avoid asking questions that do not help solve the problem, such as “Why did you do that?”
  • Provide verbal or nonverbal cues. 
    • An example of a verbal cue is to say “Stop and think, what else could you do?”
    • An example of a nonverbal cue is pausing or not acting immediately to help the person recognize the need to use a strategy such as “stop and think.”
    • Use a signal you have agreed upon ahead of time, such as a raised finger or a head nod.
  • Types of cues:
    • Direct Cue – a specific prompt. For example: “Did you look in your calendar?”
    • Indirect Cue – a general prompt: For example: “Where could you find that information?”
    • Self Cue – “Where could I find that information?”

5W Strategy

Therapists may also teach the 5W strategy to help your service member/veteran learn more efficiently. Learning in the face of a short-term memory deficit can be challenging. This technique will help as it allows the person to save time. Instead of reading information over and over again, the person is taught to focus and pick out the main points of what he or she is reading.

Read and Remember 

  • Who 
  • What 
  • Where
  • When 
  • Why

Why 5W Strategy Works:
Writing out or saying something out loud reinforces accurate memory. The 5W strategy also simplifies the information so main points can be recalled.

Your service member/veteran may have difficulty at first but practice helps.

Example of the 5W strategy:
Making/taking a message – write down all 5 points (W’s) of the message

  • Who: Mom
  • What: Call about lunch
  • Where: Meet at our favorite restaurant
  • When: Friday at noon
  • Why: To talk about vacation plans

 

Feedback

Feedback means giving information to your family member about how he or she is doing. A brain injury can make it hard for a person to fully understand how he or she is behaving. Feedback from others can help the person see what is going on.

The best time to give feedback is right away, just after the situation happened. If your family member has memory problems, it can be hard for him or her to remember what happened for very long. So prompt feedback is best.

You need to give feedback in a firm but gentle manner. This may be hard at first, but keep practicing. It will get easier. A direct and supportive approach works best.

Consistency is another key. Attend therapy as much as you can to learn how to provide feedback to your service member/veteran. You can also learn how your service member/veteran tends to respond to different types of feedback. The more consistent the approach, the more likely the feedback will have a positive impact on the thinking and behavior of your service member/veteran.
 

Problem Solving

Learning how to be a good problem solver can help you and your service member/veteran cope with stress and reduce anxiety. Therapists will often work closely with your service member/veteran to improve problem-solving skills. The following simple problem-solving steps can be effective in helping to break down problem solving into a more manageable task. Writing down the answers can be helpful and allow the person to better “see” options. Reinforcing use of this technique is one way you can help with problem solving, both in the rehabilitation setting and when you get home.

  • Identify the problem. If the problem has many parts, break it down into one problem at a time.
  • Brainstorm solutions. Think of as many possibilities as you can.
  • Evaluate the alternatives. Consider the pros and cons of each possibility.
  • Choose a solution, the one that seems to fit best for you.
  • Try the solution out.
  • Evaluate the solution. If it didn’t work, try another solution until you find the one that works.

Problem Solving Worksheet


Communication Effects Overview

A TBI can cause changes in a person’s communication skills. These changes vary from person to person.

How severe the injury is and its location affect these changes.

Factors that play a role in communication problems include:

  • behavior
  • memory, attention, and other thinking skills
  • judgment
  • social skills
  • self-awareness

Communication skills are very important in everyday life. Your family member may not be able to use words to express him or herself well. This can be very frustrating. Many people with TBI do well speaking in non-stressful situations. But your service member/veteran may not be able to use these speaking skills during a stressful situation at school, work, home, or in the community.

Language problems can lead to miscommunication and confusion. This may make it harder than it used to be to make new friends and maintain old relationships. A positive note: Most people with a TBI do, in fact, speak again. Most make notable progress in the other areas of communication over time.

A speech language pathologist (SLP) is the team member who treats communication problems. Your service member/veteran may be able to speak, but may need training to:

  • understand and remember what is being said
  • express needs, wants, and ideas clearly to others

The SLP treats problems with speech, voice, and memory.
 

Related Information:
Cognitive Effects
Neuropsychological Evaluation
Common Cognitive Effects
Memory Compensation
Communication Effects
Behavioral Effects
Emotional Effects
Glossary
Frequently Asked Questions
"He had visual field deficits right after the injury. They’ve since gotten a little bit better, but he still has visual field deficits. He lost hearing in his right ear, so he can’t hear sometimes when I’m trying to talk to him." -  Aimee W.

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