Cognitive effects

Attention is being able to focus 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.

The changes in attention that can happen after a brain injury can make it hard to follow a conversation, hard to work, or make it unsafe to cook a meal or drive. In the early stages of recovery, you might not be alert enough to communicate or be fully aware of your environment. If you can focus on something, it may only be for a short amount of time.

At times, one small detail or focus on the wrong information may cause you to be distracted. These distractions could be internal: for example, you might be distracted because you need to go to the bathroom. The distraction could be external: for example, while talking, your attention may be on someone’s tone of voice or clothing rather than what they are saying. You could be trying to pay attention to words, how you look, noise from the street, and other activity in the room all at the same time.

If you can’t concentrate, it’s hard to finish a task. You might know what you need to do, but have trouble keeping track. We all have problems concentrating, especially when we’re tired or don’t feel well. For individuals with a brain injury, it can be so difficult to pay attention or concentrate that it’s hard to do even the simplest task like washing your hands or dressing.

Tips to help with concentration and attention

• Ask people to repeat the things they say to you and break it up into small bits of conversation. This will help you absorb the information.
• Break tasks into small steps.
• Engage in hobbies or activities that you enjoy and can do. Card games, puzzles, and reading help develop concentration and are entertaining at the same time.
• People who have trouble focusing may get tired quickly. Make sure you take short breaks to give your brain a rest.
• Reduce distractions; have only one person in the room, turn off the TV or radio, and try to limit the number of things you’re doing at the same time.
• Take away time pressures. Don’t rush through a task or expect it to be done perfectly.

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

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

Tips for judgment and problem-solving

• Ask for feedback on your behaviour. You can ask your psychologist, occupational, or speech therapist for ideas on how to do this
• Consider the possible reactions of people that would be affected by your decision
• Make a list of choices – or ask your caregiver to give you choices – when it comes time to decide. For example, have your caregiver ask if you want to go for a walk, practice exercises or watch TV instead of asking what you want to do
• Reduce distractions that could affect your decision-making process
• Take extra time to clearly think about your decision
• Try planning and reasoning out loud so you can more clearly think about your decisions. You can also have a caregiver listen to you and make suggestions
• Work with a caregiver, friend, or family member on decisions whenever possible
• Write down the important things to think about when making a decision. This gives you a guide to refer to during the process
• Write down problems or situations from the past – they can help with decision-making in the future.

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

• Difficulty expressing yourself
• Difficulty finding words
• Difficulty understanding others
• Trouble with conversation
• Trouble with facial expressions or tone
• Difficulty organizing your speech
• Not being able to respond appropriately

These challenges can come from physical issues with control over your tongue, mouth and throat muscles. They can also arise from damage to the parts of the brain that control and understand language (this is called aphasia).

• More information on speech, language and brain injury

Tips to improve communication skills

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 you communicate:

• Find a place where you feel comfortable talking and listening, where you don’t feel pressured or distracted
• Don’t turn on a TV, radio, or other noisy items when you want to communicate with someone
• Talk and listen to one person at a time. Group conversations can be overwhelming and hard to follow
• If you don’t understand someone, ask them to repeat themselves or use different wording
• Take your time to think and speak – there’s no rush

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 appropriately.

Memory is generally divided into two categories: declarative and non-declarative. Declarative memory is things that can be clearly remembered such as specific past events (episodic memory) or knowledge and facts (semantic memory). Non-declarative procedural memory is memory that is retained as a skill or a motor response.

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.

Problems with memory can affect progress in all areas. If memories fade quickly, you won’t be able to learn from new experiences, remember that you’re making changes or remember that you’re improving. This can have a huge impact on rehabilitation. In therapy, you’re learning mobility skills, how to use assistive devices, how to communicate and how to process information. If you have trouble remembering what you learned from one day to the next, progress may be slower.

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.

Memory recovery is often slow, and in some cases a person may never fully recover. This can be incredibly frustrating and upsetting for both you and family/friends. It’s important to be gentle with yourself, and as you cope with the changes surrounding your brain injury that you do what you can to take care of your mental and emotional health.

• More information about mental health after a brain injury
• More information about adjusting to a new self after brain injury

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

Tips to help with memory

• Be patient with yourself. It’s frustrating to not be able to remember things, but you’re working hard. Take the time you need, ask people to repeat themselves if needed, and be kind to yourself when you’re working on your memory
• Choose activities that are familiar to you – this will help you form memories, and create enjoyable experiences
• Having routines helps all of us remember, so consider creating routines for events that are repeated everyday, like when you have meals or where you 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 if you need to remember them. Have paper and a pen or pencil with you so that you can write down important points, or ask the person with whom you’re speaking to write down what they want you to 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. You may not be able to think ahead or lack follow-through to finish a task. Your thinking may be disorganized and incomplete. This may show up as repetitive movements or comments. You 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. For example, you need to be able to do laundry, so you have clean clothes. This means you need to know when to add soap, how to set your washing cycle, and how to set your drying cycle. You may not be able to plan out all the steps right away, but by setting goals and working with rehabilitation specialists, you can develop your planning skills.

Tips to help with planning

• Break down the task into small steps. For example, when making a salad, first prepare the lettuce. When this is done, proceed to the next step, and so on
• Have a caregiver, friend, or family member clearly and briefly explain the activity before you start
• Read instructions or have directions read to you slowly so you have time to understand and respond
• Reduce distractions, reduce the demands, and give yourself extra time to problem-solve
• Routines and schedules outlining future events help with better organization
• Use a checklist so that you can check off each step of a task as you do it
• Use a calendar or whiteboard to provide visual cues and reminders
• When possible, help with household chores (as much as you can do). Things like setting the table, washing the dishes, or preparing a salad need planning but may be familiar enough that you can do them easily. These kinds of activities will help you practice step-by-step planning
• Daily activities tracker

It’s common after a brain injury for a person not to be as self-aware as they were before. For example, an injured person may not be aware of what they can’t do anymore. They may not notice or remember the changes in themselves, be in denial, or grieving those changes, which are emotional responses. 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 spot in yourself. This is when you need the help of therapists, caregivers, family, and friends. Your support team will help you figure out the best ways to receive feedback and identify ways to improve self-awareness. For example, perhaps you’re more likely to listen to a sibling vs. a parent, or a doctor over a family member when receiving feedback.

• More information on coping with a new self