Impaired Cognition: Frequently Asked Questions

What Is Cognition?

Cognition is another word for thinking and the process that describes how we understand and interact with the world. Cognition also describes how the brain perceives and expresses experiences.

What Is Meant by Impaired Cognition?

When a person is diagnosed with impaired cognition, it means their skills and abilities may have diminished or disappeared as a result of a medical problem. There are special names for some of these impairments; for example, an impairment in language skills that makes it hard for people to speak or understand speech is called aphasia.

How Is Cognition Affected by Brain Injury?

ince a brain injury can occur in any part of the brain, any thinking abilities may be affected. This could include attention, communication, visual perception (the ability to understand what is seen) and memory. Very often, the parts of the brain located toward the front of the skull are most severely damaged. Typical impairments due to injury in this area include:

• Problems with attention, concentration and organization
• Difficulty remembering things that happened since the injury
• Lack of awareness of your behavior or how others see you
• Appearing inconsiderate, selfish, and not caring how others feel or just not being aware of how you make other people feel.

What is “Minimal Consciousness?”

People who are minimally conscious are more awake than someone in a deep coma, but they may actually have little awareness of their surroundings. They may open their eyes and look around the room, but not respond to what they see or hear in the room. Minimally conscious people may benefit by having things to think about; for example, having visitors, talking to them, having the television on, or reading aloud. While none of the following activities has been proven to help recovery, they could be used to assist the individual to get started:

• It may help for the minimally conscious person to start using different senses again, so talking to them or playing music is a reasonable thing to do
• Gentle touching or holding hands
• Having sweet smelling flowers in the room
• Playing recorded messages from family or friends
• Using complex stimuli such as audiobooks or television usually is not helpful.
• When around a minimally conscious patient, avoid speaking as if they are not there and cannot hear you.

How Does Brain Injury Affect Actions and Feelings?

Sometimes brain injuries damage the part of the brain that controls emotional expression. As a result, people may become angry much more easily and their anger may be much more forceful. Often, people with this problem feel embarrassed after an angry outburst because they know their reaction was inappropriate. Other people may laugh or cry at inappropriate times because of the same problem. Doctors describe this lack of control of emotions with a number of terms including “emotional lability” or “affective dysregulation.” People may also act before they think and may do and say things they would never have done or said before. Such behavior is sometimes described as “impulsivity” or “disinhibition.”

How Long Does It Take to Recover From a Brain Injury?

Recovery time depends on the severity of the injury. If someone was unconscious for less than 30 minutes, the recovery usually occurs within three months. If a person was unconscious for more than 24 hours, recovery may take up to a year. Recovery is usually most rapid in the days and weeks immediately after an injury (improvements can often be noticed from one day to another). Then, recovery slows down and improvements may not be noticeable unless compared month to month.

What is the Definition of Recovery?

Rehabilitation helps people to recover but recovery may not mean completely returning to the way things were before the injury. One way to think of recovery is that the person with the injury (impairment) has acknowledged that there is a change, has learned how to do things differently or compensate for problems, and has decided to do as much in life as they can. It means enjoying life as much as possible and feeling good as a person while being aware of one's limitations. It also means feeling valuable to others. It does not mean being exactly the same as before the injury. Recovery is an ongoing process, and after all, everybody changes over time.

It has always been very difficult to predict the amount of recovery someone has after brain injury. When a serious injury results in unconsciousness for a long time, there are usually some lasting effects, but it is hard to predict how much they might interfere with normal life. Depending upon how severe the injury, the effects and changes to life can be permanent. In less severe cases, some functions may recover, while others remain weak, such as short–term memory. Either way, recovery can take a long time. At some point, it becomes hard to know if improvement comes from brain recovery or just learning to do things differently.

What Can Help with Recovery from Brain Injury?

Most important is to work at recovery rather than just sit around and wait for improvements to happen.

• Therapies are essential, even after leaving the hospital.
• Keep to a routine and stay active. Think of the brain as a muscle; it will weaken if it is not exercised.
• Look for ways to stimulate thinking. Games, puzzles, reading and performing everyday tasks that offer mental challenge can be useful.
• Focus on doing only one thing at a time.
• Try to strike a balance between doing too little and too much. Go slowly and set realistic goals for the things that you used to do.

Which Activities Could Interfere with Recovery?

• Use of recreational drugs and alcohol can interfere with recovery.

  These chemicals have direct effects on the brain and can impair judgment and put a person at risk for further injury. Be careful when using them, if at all, and consult with your doctor if you have questions about any particular substance.

• Avoid risky activities like extreme sports that could cause another brain injury.

What about Returning to Work, School, or Driving?

Work (or school) and driving involve very complex behaviors. Some of these activities can be resumed as soon as a person becomes aware of their limitation, has mastered some techniques to make up for weaknesses, and has realistic goals. Limitations due to the injury may, however, present difficulties. Doctors and therapists will have advice on these matters.

Driving can be very dangerous if there are impairments that affect vision, reflexes or problem solving. A special driving evaluation may be necessary.

How Can I Talk to Me Children About Brain Injury?

Children need to know some basic things about brain impairment; for example people with brain injuries may act confused or have trouble remembering or talking about things. Remind your children that a brain impaired person is not ”retarded”, ”stupid” or ”child like” even if other adults use those labels. Find out your child's questions. If you do not have answers, check with a trusted professional to help you find the appropriate response.

How Does a Brain Injury Affect Family?

A brain injury can be scary and confusing, resulting in a number of family reactions. Many of these reactions are understandable, but not helpful. For example:

• Treating the person with brain injury like a child or a baby
• Feeling angry at the person with the impairment because of a sense that they were somehow responsible for what happened
• Disagreeing and arguing about what is best for the individual
• There may be times when some family members are upset and even withdraw from family contact. With patience and time, hopefully they will come to a better understanding of the injury and re–establish contact.

Brain impairments can make family members feel personally vulnerable, frustrated and misunderstood. Like any other serious family problem, it is not always possible to agree about what to do, but it is important to listen to different points of view and treat others with respect and kindness.

What Should I Do If My Family Member with Brain Injury Has Problems with Anger and Becomes Violent?

Sometimes people have difficulty with emotional control after brain injury and this can include having a short temper. Family members need to learn different ways to respond to someone with a brain injury who is easily angered.

• The best way to deal with violence is to learn how to prevent it. Watch for patterns or triggers that set off the person with brain injury; try to avoid responses that only make anger build.
• Remain calm. It is usually not helpful to argue logically when a person with brain injury has become upset.
• Try diversion or redirection in any form. This takes away the irritation and allows the person time to calm down.
• Try to avoid physical restrictions and allow the person (within limits) to freely express themselves physically and verbally.
• If the situation becomes physically violent or threatening, direct appeals for calm can be tried, but may not have the desired effect. In extreme situations, where physical restraint seems necessary, try to have a phone available and numbers to call (such as the doctor or police) for quick, efficient use. Do not try to handle these situations alone.
• If anger control is a chronic problem, ask your doctor about the possibility of medications to help manage the behavior.

Additional Resources

American Stroke Assc., 888-4-STROKE

Brain Injury Assc., 703-236-6000

Gronwall, D, Wrightson, P, and Waddell, P., 1999. Head Injury: The Facts: A guide for families and care-givers. Oxford Press.

National Stroke Assc, 800-STROKES

Osborn, Claudia, 1998. Over My Head: A doctor's own story of head injury from the inside looking out, Andrews McMeel Publishing

Stoler, D and Hill, BA Coping with Mild Traumatic Brain Injury Avery Press, 1998