Cognitive effects

Attention is being able to focus on something. After a brain injury, a person may have trouble focusing/concentrating on something. There are several different types of attention, including:

• Selective (focused) attention: This is being able to ignore distractions. Examples of challenges with selective focused attention may include being unable to focus when there are multiple people talking or being easily distracted while driving. Other examples include forgetting what you were going to get from the bedroom, or trouble preparing a meal.
• Sustained attention: This is how long you can concentrate on an activity or task. Sustained attention depends on factors such as the task, how tired you are, and environmental distractions.
• Spatial attention: This is your ability to be aware of specific locations in the environment.
• Alternating (divided) attention: This lets you switch from one task to another without losing track of what you’re doing, and to keep track of several things at once. This may be difficult to do after a brain injury.
• Attentional capacity (‘working memory’): This is how much information you can take in at once without getting overloaded and your ability to use that information. For example, the average adult can hear and repeat a 7-digit phone number but usually won’t remember it 5 minutes later. After a brain injury, you may not be able to take in as much information.
• Prospective memory: This is the ability to plan, retain and retrieve an idea as planned. For example, if you need to run an errand, you need to plan to stop at the store, remember to stop at the store, and complete your errand. This memory can be challenging for someone with an acquired brain injury because planning can be difficult.

If the individual can maintain their attention, it may only be for a short amount of time and they may experience restlessness. At times, one small detail or focus on the wrong information may distract them. These distractions could be internal. For example, they might be distracted because they need to go to the bathroom. The distraction could be external: for example, while talking with you, their attention may be on your tone of voice or your earlobe rather than what you are saying.

If the person with the brain injury can’t concentrate, it’s hard to finish a task. They may know what they need to do, but have trouble keeping track of what they are doing. We all have problems concentrating at times, especially when we’re tired or don’t feel well. For the person with a brain injury, it can be so hard to concentrate that they can’t do even the simplest tasks, like washing their hands or dressing themselves. Since it’s common to feel very tired (fatigued) after brain injury, that can also be a reason the person seems to be so up and down during the day.

While these changes may be discouraging for both the individual and the caregivers, it’s important to remember that with the appropriate rehabilitation and follow-through, over time there can be improvements. Actions like maintaining a routine and practicing patience will help as they work on increasing their attention span.

Tips to help with concentration and attention

• Be sure you have their attention before starting a task or a conversation
• Encourage hobbies or activities that they enjoy and can do. Card games, puzzles, and reading are examples of activities that help develop concentration
• Give new information and tasks in small bits and repeat it often. Have them repeat back the information to be sure they’re listening
• If their mind is wandering, use your voice to try to keep their attention. Show excitement in your voice and use gestures to bring their attention back to the task. If they seem to be withdrawing from you, try a quiet, soft-spoken approach
• Offer positive reinforcement when tasks are completed
• Reduce distractions; have only one person in the room, turn off the TV or radio
• Take away time pressures. Don’t rush through a task or expect it to be done perfectly
• Watch for signs of fatigue and encourage them to take breaks as necessary

Problem-solving and judgment may be impaired after a brain injury. An individual living with brain injury might have trouble judging a situation, figuring out what the right response should be, or act on their first impulse. Their thinking style may not be flexible – in other words, once they make up their mind, it can be hard to change it.

Problem-solving skills are incredibly important for living independently and safely. They may need to work with specialists or caregivers to develop these skills.

Helping with judgment and problem-solving

• Make a list of choices when it comes time to make a decision. For example, ask them if they want to go for a walk, practice rehabilitation exercises or watch TV instead of asking what they want to do.
• Provide constructive feedback on their behaviour. You can ask a psychologist, occupational therapist, or speech therapist for ideas on how to do this.
• Reduce distractions that could affect the decision-making process.
• Try encouraging them to plan and reason out loud so they can more clearly think about their own decisions.
• Work with the individual to make decisions together whenever possible.
• Write down problems or situations from the past – they can help with decision-making in the future.
• Write down the important things to think about when making a decision. This gives them a guide to refer to during the process.

After a brain injury, it’s common to have trouble with speaking, understanding language, writing and reading. This includes:

• Difficulty expressing oneself
• Trouble with conversation
• Trouble with facial expressions or tone
• Difficulty organizing speech
• Not being able to respond appropriately

We know that more than one part of the brain can be injured. This means that there could be more than one issue affecting communication. For example, the person may have damage to the language areas of their brain or damage to the area that controls pronunciation. Damage to other brain areas may cause issues with the thinking skills you need to be a good communicator. The person may be confused, disoriented, and impulsive, talk too much, or be withdrawn and silent. They may have trouble staying focused on an appropriate topic and their speech may ramble disconnectedly (language of confusion). They may repeat their speech or activity. This is called perseveration and is outside their control.

Not many people will have all these issues at once, but it is possible for several to be combined, especially early in recovery. If the person has a lot of trouble communicating, they may need another way to communicate, such as using a computer or picture board.

Changes in understanding (comprehension)

It can be difficult for a person with a brain injury to understand/comprehend conversation or their surroundings. They may be:

• Unable to hear the speaker’s voice and focus on it
• Unable to get meaning from words or use speech sounds to make words
• Unable to match the meaning with information stored in the brain

Problems with understanding can range from only affecting the person at certain times (like when they are tired) to affecting them most of the time. For example, a comprehension problem may make it hard to read or carry on a conversation.

Changes in expression

To communicate with others, we need to be able to:

• Come up with what we want to say
• Put our response into words in our mind
• Activate the muscles controlling voice and speech
• Judge whether we are being appropriate

It’s important to be able to form words to share thoughts. If the brain injury has damaged the part of the brain responsible for expressive language, the person may have trouble making sentences or finding the right words.

Changes in speech and voice

Sometimes all stages of communication work as they should except for the process of making the sounds of speech. Damage to certain areas of the brain can interfere with messages to the muscles of the tongue, lips, jaw, voice box, and other areas. The result may be a weak, breathy voice, or slurred speech sounds. Sometimes the brain gets a mixed message of how a word should sound. The person might struggle to get the right sounds in order or have trouble speaking at all.

Tips for communicating

A speech-language pathologist can help identify the best strategies for successful communication when a person has a brain injury, but there are a few general guidelines that can help anyone with communication challenges:

• Create an easy, non-demanding atmosphere where the person with brain injury feels free to communicate without time constraints or a pressure to perform (i.e. putting them on the spot, or making them the centre of attention)
• Reduce background noise and other distractions when talking with the person
• Consider limiting the number of people in the conversation, especially if the person with brain injury has challenges switching attention or keeping track of multiple speakers
• Get the person’s attention before speaking, and try to stay in that person’s field of view while speaking (i.e. avoid speaking to them if they can’t see you)
• Speak in direct, clear, short sentences
• Keep an adult tone of voice and vocabulary
• Consider asking yes/no and multiple-choice questions, if the person has challenges coming up with words or ideas
• If a person has trouble expressing themselves, give them time to communicate in the best way they can. Give them your full attention and be patient until they finish the thought. Don’t finish sentences for the person or give them cues or “hints” to what you think they want to say, unless they ask you to
• If you’re not clear on the person’s meaning, repeat or paraphrase their message to make sure you understand it
• Don’t ask too many questions at one time. Wait for a response to one question before asking more
• If the person with brain injury does not give the listener a turn to speak, politely interrupt and say that you would like to speak
• Be honest and admit when you don’t understand. Communication breakdowns happen to everyone, even with the most supportive partner

Communication involves two people, so make sure there’s plenty of active listening as well as talking.

One of the most important things you can do is to keep your relationship with your loved one as natural as possible: in other words, don’t become too much like a teacher. It’s important to practice communicating, but it’s equally important to be their friend and family.

It is also important to show patience and understanding. This is an adjustment for everyone and tempers and frustration can run high. It’s normal to experience those feelings, but it’s important to make sure you are doing what you can to address those feelings constructively.

• More information on coping with caregiver stress

How memory is affected depends on the brain injury. Some individuals lose their memories of time before or immediately after the injury. Others are unable to make new memories, while still others forget skills or motor responses that used to be second-nature, although this is less common.

The most common types of memory loss after a brain injury are:

• Short-term memory loss: This means you can’t remember things that just happened and are often influenced by problems with attention.
• Amnesia: This most commonly refers to loss of declarative (episodic) memory after damage to specific areas of your brain’s memory system. Amnesia can be divided into anterograde and retrograde.
  • Anterograde amnesia: This means the inability to form new memories, after the time of injury, and is often the result of short-term memory loss.
  • Retrograde amnesia: This means you’ve forgotten what happened before your brain injury.

On rare occasions, a person with memory loss may remember things that did not happen or twist events. This is called confabulation, and it’s done automatically without the person realizing it: they don’t know that they are making up information and tend to not fully recognize the impact of their brain injury.

During the assessment stage of therapy, therapists will test memory for events that happened:

• Before the accident (remote or retrograde memory)
• In the past few minutes (immediate memory)
• In the past few minutes, hours, or days (recent or anterograde memory)

Immediate and recent memory tends to be more affected by a brain injury than remote memory.

Problems with memory can affect progress in all areas. If memories fade quickly, they won’t be able to learn from new experiences or that they are improving. This can have a huge impact on rehabilitation. In rehabilitation, they are learning mobility skills, how to use assistive devices, how to communicate and how to process information. If they have trouble remembering what they learned from one day to the next, progress may be slower. Memory recovery is often slow, and in some cases a person may never fully recover. This can be incredibly frustrating and upsetting for both of you. It’s important to be patient, and as you cope with the changes surrounding their brain injury, do what you can to take care of your own mental and emotional health.

• More information about mental health of a caregiver after a brain injury

There are steps you can take to help with any memory changes they may be experiencing.

Tips to help with memory

• Be patient. Repeatedly asking questions does not increase the likelihood that they will remember something. It may make the person feel defensive and hurt. Instead, give them the time they need, and don’t get upset if they can’t remember something.
• Consider setting the stage for a conversation rather than asking the person to remember from scratch – e.g., “I had a good time when we went to the park yesterday and saw the dog-walkers”, vs. “Do you remember what we did yesterday?”
• When choosing activities, consider those that are familiar to the person and you know they like, like watching a familiar sports team or playing a game you both know well.
• Create routines for events that are repeated everyday, like when they have meals or where they put the housekeys.
• Try to use one calendar system for keeping track of events, rather than several different systems in different rooms or situations.
• Use any calendar or routine consistently – consistency helps make habits and avoids confusion.
• It’s a good general rule to write things down to help the person remember.
• You can buy devices that shut off stoves and other appliances automatically. This can help to prevent safety hazards.

Many people with a brain injury find it hard to plan, begin, and finish an activity. They may not be able to think ahead or lack follow-through to finish a task. Their thinking may be disorganized and incomplete: this may show up as repetitive movements or comments. They might act impulsively by doing something quickly without thinking or need a lot of time to understand information and respond the right way. Planning is an important part of building independence. It will take a while but with your support and rehabilitation plans from occupational therapists, planning skills can be developed – although they may not reach the same level as before the accident.

Tips to help with planning

• Clearly explain activities before the person starts.
• Read directions to them slowly so they have time to understand and respond.
• Reduce distractions, reduce the demands, and give them extra time to problem-solve.
• Routines and schedules outlining future events help with better organization.
• Use a calendar or whiteboard to provide visual cues and reminders.
• Use a checklist so that they can check off each step of a task as they do it.
• When possible, ask the person to help with household chores (as much as they can do). Things like setting the table, washing the dishes, or preparing a salad need planning but may be familiar enough that they can do it with ease. It will also help them practice step-by-step activities.

It’s common after a brain injury for a person not to be as self-aware as they were before. For example, they may not be aware that there are some things they can’t do anymore. They may not notice or remember the changes in themselves and be in denial. Or they feel pressure to return home or return to work even if they are not completely ready. This may lead to the person overestimating their abilities and underestimating their problems.

Self-awareness is difficult to see on your own. This is when your loved one needs the help of therapists, caregivers, family, and friends. Provide them with realistic feedback and positive reinforcement. You can help them identify ways to improve self-awareness. For example, perhaps they are more likely to listen to a sibling vs. a parent, or a doctor over a family member when receiving feedback.