Cognition is another term for how we think and learn.
Cognitive changes — changes in thinking — are very common after a TBI.
Thinking takes place in the brain. When the brain is injured, thinking is affected. Thinking may be different and harder than it used to be.
In most cases, cognitive problems improve over time. Time, rehabilitation, and the natural healing of the brain all help thinking to improve.
Cognitive recovery often takes longer than physical recovery. Try to be patient. Remember that it is an injury to a specific part or parts of the brain that causes cognitive problems.
This chapter reviews cognitive changes your family member with TBI may experience. Strategies are listed that may help you and your service member/veteran with TBI to make up for the loss of some thinking skills.
Just as with physical problems, not everyone with a TBI has the same cognitive problems. The neuropsychologist, OT, and speech language pathologist are the health care team members who identify and treat cognitive problems.
What is a Neuropsychological Evaluation?
Module 1 described tests — like MRIs and CTs — that doctors use to examine the brain and its physical injuries.
There is a different test to figure out how well the brain is working, i.e., how well the person is thinking. This test is called a neuropsychological evaluation. A neuropsychologist conducts this test.
First, the neuropsychologist will learn as much as possible about the person and what he or she was like before the injury. He or she may ask you questions about your family member.
Next, the neuropsychologist will use a number of different tests to see how the person’s brain is working and where there are cognitive problems.
Testing may measure:
- attention span
- language (receptive and expressive)
- new learning
- mathematical reasoning
- spatial perception
- abstract and organizational thinking
- problem solving
- social judgment
- motor abilities
- sensory awareness
- emotional characteristics
- general psychological adjustment.
These tests can take several hours to complete.
Based on what the tests show, the health care team will develop treatment plans to improve cognitive problems. Occupational therapists (OTs) and speech language therapists are the members of the health care team who do this work.
What are Common Cognitive Effects?
Most people with severe TBI experience some confusion after their injury. It is expected.
Sometimes confusion only lasts minutes. Other times, it can last days or even weeks.
Keeping your family member safe, reminding him or her about what’s going on, and offering reassurance are important during this stage of recovery.
What you might see:
- Disorientation (not sure of where he or she is, time of day, what has happened)
- Seems in a fog, staring blankly
- Confusing times/tasks in schedule of activities
- Confusing past and present events
- Making up convincing stories to fill memory gaps (This is called confabulation. See page 43 to learn more.)
How you can help:
- Keep your family member oriented. Put calendars, clocks, family pictures, and/or a sign about where he or she is and what has happened, in his or her room. A list of health care team members and what each one does may also be useful.
- Use a notebook to plan for and log events. Have your family member refer to it for details of daily events.
- Frequently remind your service member/veteran of correct details of past and present events.
- Limit changes and provide structure in a daily routine.
Slowed Speed of Processing
Many people with TBI complain that their thinking and processing of information is much slower than it used to be.
This problem improves over time. It can be frustrating in today’s fastpaced world.
Slowed speed of processing can add to confusion.
What you might see:
- Taking longer to answer questions
- Taking longer to understand things that were easily understood before
- Taking a long time to react and respond.
How you can help:
- Slow down and simplify information.
- Break complex tasks and activities down into smaller steps.
- Allow extra time to respond to questions and to comprehend and learn new information.
- Avoid situations that are overstimulating (e.g., noise, crowds).
- Suggest a different activity or topic of conversation to help the person remain on task.
- Encourage your service member/veteran to ask others to slow down and repeat information.
“Processing is very slow, just taking things in — he would repeat things over and over. You try to do everything for them. They’re trying to do things and you’re tired… then you start over again trying to do everything for them to speed things up, which doesn’t help. They need to do things for themselves as much as possible. Rehab is the main thing.”
— Denise G.
The ability to focus, to pay attention for a long time, and to do more than one thing at a time is controlled by the brain.
TBI can and often does affect all forms of attention.
Attention is important because paying attention is the first step to learning and remembering.
It is not uncommon for a person with a severe TBI to only be able to attend for a few minutes at a time in the beginning.
What you might see:
- Short attention span, sometimes only minutes in duration
- Easily distracted
- Difficulty in attending to one or more things at a time
- Inability to shift attention from one task or person to the next
- Difficulty completing tasks.
How you can help:
- Focus on one task at a time.
- Be sure you have your service member/veteran’s attention before beginning a discussion or task.
- Reduce clutter at home and in the work environment.
- Perform tasks in a quiet environment.
- Remove distractions and noises that you don’t need. As best as possible, use timers (watches, PDAs, or other devices) and checklists in the calendar/memory notebook to help with completion of tasks.
- Refocus attention to the task at hand.
- Expect a short attention span. Schedule rest breaks and/or stop an activity when you notice drifting attention.
- When signs of distraction arise, insert a rest break (“Let’s do this for another 5 minutes and then take a 15 minute break.”).
- Present verbal or visual information in limited amounts.
Difficulties with Memory
Memory problems happen often after a TBI. Past memories or longterm memory is nearly always intact. Recent memory, called short-term memory, is much more often affected.
Short-term memory often gets worse as fatigue increases.
Short-term memory usually improves over time.
Memory compensation means learning to use memory tools, such as a calendar, planner, organizer, or memory notebook.
Signs with instructions, lists, and notes are other effective memory compensation tools.
Ask the health care team about which memory tools would be helpful for your family member.
“He has severe memory issues. He has a PDA to keep him straight on what appointments he has, what medications he needs to take, things like that. That’s helped him a lot.”
— Meaghan L.
These tools may also help you remember everything you need to do!
What you might see:
- Can’t remember information from day to day about people, conversations, places, events, appointments, dates, and telephone numbers
- Keys, wallet, etc. are frequently lost or misplaced
- Repeating questions or the same story over and over again
- Can’t learn new information and use it in everyday life.
How you can help:
- Get the person’s attention when you are trying to teach, do, or discuss something.
- Break new information down into categories or “chunks.” List and review them in order.
- Set up a routine of daily tasks and follow it.
- Help your family member use memory aids on a regular basis. Write down tasks on a calendar or notebook. Check tasks off when done.
- Explore use of “high tech” memory aids. Personal digital assistants (PDA), wristwatch alarms, and cell phones can remind your family member when to do a task, such as taking medication. Before spending money on these devices, ask the OT or speech pathologist whether your family member can learn to use the technology.
- Buy a pill box and label each compartment with the time and day that medication should be taken. Write the names of medications and when to take them into the calendar/memory notebook.
- Keep personal and household items in the same place.
- Try to pair new information with things the person is able to recall.
- Provide verbal cues for recall and help fill in memory gaps.
- Talk to your service member/ veteran about the activities and events of the day to help build memory.
- Have your service member/veteran review plans for the following day.
- Learn and use a cueing system (see section on cueing at the end of this chapter).
- Present information in more than one way, including hearing, seeing, and doing. Each person has a different learning style. Ask the neuropsychologist how your family member learns best.
- Role play in order to reinforce new learning.
Planning and Organization Problems
Organization and planning skills are often affected by TBI.
These skills improve over time. The health care team will work with your family member to develop better organization and planning skills.
You may need to remind your family member again and again to use the skills he or she learns in therapy until they become a habit.
“His biggest problem is naming. He has a hard time naming anything. So we have picture cards. We go through the cards all the time, just to get him to name an object. We can even go through the house or if we take a walk, I ask him to name things... what is this? This is a sidewalk. What is this? This is a tree. What sort of tree?”
— Patty H.
“He has a PDA, and he does make lists, but that’s a battle in itself. Early on I had sticky notes everywhere and lists of things that he needed to do when he got up in the morning, things that he would need to get before he left for his therapy, that kind of thing.
And over time I see that we’re regressing in that department, so I’m actually in the process of getting those lists back out because he definitely has a memory issue, even with taking his medication every day. There will be times that he forgets.”
— Sandy M.
What you might see:
- Problems organizing time to get things done
- Problems understanding which tools are needed to complete a task and getting them together
- Problems breaking down complex tasks into smaller steps
- Having a hard time getting ready for work, school, and appointments
- Being late for appointments and work or school
- Having a hard time starting a task
- Problems making plans and completing them
- Problems setting goals
- Trouble prioritizing
- Looking disorganized.
How you can help:
- Begin with small, realistic tasks.
- Work with your family member to get organized at home. Keep a family calendar posted on a wall. Use reminder notes and cue cards (example at the end of the chapter).
- Have a place for everything and keep everything in its place. In particular, keep your service member/veteran’s belongings in certain places.
- Turn off the radio/TV or other distractions when tasks need to be done.
- Use memory aids such as calendars and notebooks to plan, write down, and check off tasks when done.
- Use a tote bag or backpack to organize needed items for the day.
- Work with your service member/veteran to decide which information or activity has the highest priority.
“He has his talking watch because he has some issues with his vision. So his watch tells the date and the time. And he also has a beeper that’s preset by speech therapy, and it goes off five minutes before he has an event, like therapy or something scheduled. The beeping, the auditory cue, lets him know to look at his book, which is just a three-ring binder notebook. It has his schedule, like Monday through Friday and a time on one side. So he picks the day and then looks at the time according to what his watch says, and then he knows where he’s supposed to be.”
— Meredith H.
Difficulty with Decision Making and Problem Solving
Making decisions and solving problems take a lot of thinking. Both can be hard for people with TBI.
Simple decision making and problem solving are easier than more complicated decision making and problem solving.
What you may see:
- Taking a long time to make a decision
- Making inappropriate and/or potentially harmful decisions
- Problems reasoning
- Responding impulsively to situations
- Having a hard time recognizing problems
- Slow to think of alternate solutions to problems
- Tendency to be “concrete” in terms of problem solving, that is, difficulty making inferences
- Taking things literally.
How you can help:
- Avoid having your service member/veteran make decisions when tired, hungry, or under stress.
- Help your family member to weigh options and consequences of a decision.
- Give your service member/veteran time to make a decision. Be patient and talk him or her through the possible options.
- Limit the number of possible choices. Two or three choices is best. Too many are often overwhelming and can increase indecisiveness.
- Avoid making last minute decisions.
- Practice identifying a problem and following through with evaluating the options (see tips for problem solving at the end of the chapter).
Confabulation is a memory problem. It happens when a person with a brain injury makes up false memories.
These memories could be about past events that never happened. Or they could be memories of actual events that the person puts in the wrong time or place.
Sometimes these memories are very detailed and the person honestly believes the events happened.
Confabulation is the direct result of injury to the brain. It may go away on its own.
The health care team will work with your service member/veteran to reduce the effect by helping him or her to become more aware of it.
What you may see:
- Making up convincing stories to fill memory gaps.
How you can help:
- Don’t accuse your family member of lying.
- Gently help your family member become aware that this memory is not accurate.
How Can You Help to Build Thinking Skills?
Occupational therapists (OTs) and speech language therapists are the members of the health care team who teach cognitive skills.
They teach memory compensation skills. They also develop systems for cueing and providing feedback to your service member/veteran.
You can learn a lot from these therapists about how to use these techniques. The more everyone uses these techniques, the more benefit to your family member.
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.
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.
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.
“We would play Trouble, where you have to count how many squares you move. We would play Connect 4. We played Phase 10, Skippo, Uno, and sequence games. We played board games where you have to count your spaces. In the beginning, one of the things we did was we got the little children’s blocks where four blocks make a picture, and then another four blocks make another picture. In the beginning, he couldn’t put the four blocks together to make a picture. He couldn’t figure out what picture went with what. I mean, he’d have an airplane with a ladybug. He also had trouble putting the shapes into the right size hole. When you think about it, you’re thinking this is very easy, but it definitely was a challenge for him.”
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?”
Cue Card - Preparing a Meal
- Decide on a menu
- Count number of people eating
- Look at the needed ingredients
- Look in the pantry for what you have
- Prepare shopping list and shop
- Follow recipe instructions and organize time
- Serve and eat meal
- Clean up
Cue Card - Thinking Strategies
- Slow down, pause, STOP and THINK
- Take my time
- Don’t assume
- Check things off as I go along
- Ask questions to make sure I understand
- Repeat back what I heard
- Take notes
- Underline important information
- Double check my work
- Write down information in my own words
- Ask myself, “Do I want to be quick or accurate?”
- When I get bored – stretch, take a short break, walk around
- When I get angry – doodle, take a break, and then come back
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
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 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.
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.
Here are some examples of problem solving. Fill in the worksheet with examples from your own experience.
Problem Solving Worksheet
Sallie has to be at school at 8:15 and Don's medical appointment is at 8:30 across town. I can't be in both places.
Ask Terry's mom if I could drop off Sallie at her house early and she could drive Sallie and Terry to school together.
How It Worked
I can't remember what the doctor told me to do about John's memory problems.
Ask again at the next appointment.
How It Worked
I still forgot — he's not the only one with memory problems!
Nothing's changed — I still can't remember what to do.
Next appointment, I will take a notebook with me and write down his answer
How It Worked
Now I can refer to my notes and don't feel so worried about it.
“The most important piece of equipment he has is his cell phone. I said, ‘How are you going to have a phone if you can’t read and you can’t do the numbers?’ And he said, ‘Mom, you use call voice command.’ I’m thinking, gee, who has the brain injury here?
He had to tell me, and I thought, oh, my gosh, you’re absolutely right, Shane. He’s the one that came up with that. Not even the doctors brought that up.
We do have to key in the phone numbers. If he wants a friend’s number or asks for that, he’ll say, ‘Okay, here’s my phone number. Call me. When you call me, I’ll know that’s you and then I’ll have my mom key in your name. Or here’s my phone, put in your name and key in your number so I can call you.’ Andit works.
And that is our safety net because whenever he is away with someone that I’m not really sure about, I make sure that I call or he calls so that we keep that open line of communication.”
— Cindy P.
The questions below can help you reflect on your experience as a caregiver. You can write your thoughts here, copy this page and add it to your journal if you keep one, or reflect on these questions in your journal.
- What cognitive effects have you observed in your service member/veteran? How severe is the effect?
- Is there one particular instance that stands out for you? Describe what happened and how you reacted.
- What impact have these cognitive effects had on you? On other members of the family?
- What strategies have you tried to use to help your service member/veteran cope with cognitive effects? How well have they worked?
- What strategies do you plan to try in the future?
See more information included in Module 2: Understanding the Effects of Traumatic Brain Injury and What You Can Do to Help.
The Traumatic Brain Injury: A Guide for Caregivers of Service Members and Veterans provides comprehensive information and resources caregivers need to care and advocate for their injured loved one and to care for themselves in the process. The Guide was developed by the Defense Health Board, the Defense and Veterans Brain Injury Center and the Department of Veterans Affairs.