Cognitive changes

Introduction
Neuropsychology &
Assessing Cognitive Functioning
Examples of
Cognitive changes
Strategies

Introduction

The terms cognition and cognitive functioning are generally used when referring to someone's thinking processes - such as attention, problem solving, learning, memory, language and ‘higher level’ thinking processes, for example; decision making, planning and abstract reasoning skills.

Traumatic brain injury can cause many cognitive changes.

The extent of these changes can be assessed by a neuropsychologis.

There are practical strategies that can be used in working with people with specific cognitive deficits.

What is neuropsychology?

Neuropsychology is the scientific study of the relationship between the brain and behaviour. Behaviour includes actions that are observed, emotions and cognitive functions.

What is a neuropsychologist?

A neuropsychologist is a registered psychologist with specialised training in the area of Neuropsychology. They are often based at a hospital or rehabilitation unit and work with different groups of people with acquired brain injury, including traumatic brain injury, stroke, dementia, neurological disorders and alcohol related brain damage.

In a TBI setting, a neuropsychologist will:

Perform a neuropsychological assessment to establish a profile of cognitive strengths and weaknesses following a TBI
Provide feedback of neuropsychological findings to: o The person themselves o The family o Services involved with the client
Work with the client, their family, their carers, therapists and other services involved in their rehabilitation to develop and recommend strategies to help compensate for cognitive and behavioural changes

How does a neuropsychologist assess cognitive and behavioural changes?

A comprehensive neuropsychological assessment includes:

Clinical interview
History taking
Getting a corroborative history from others
Clinical observation
Neuropsychological testing – using a range of standardised tests that have been restricted for use and interpretation by registered psychologists

Cognitive changes

Examples of effects of some common cognitive changes are:

1. Information processing

slowed processing
poor mental tracking
fatigue

2. Attention

short attention span
poor concentration
poor attention to detail
easily distracted

3. Memory

difficulty learning and remembering new information

4. Problem solving

difficulty working out how to do things

5. Flexibility

unable to shift to or think of a new solution/method
may perseverate (repeatedly refer to the same topic or keep returning to that topic)

6. Planning and organising

poor preparation, eg. starting something without considering options
difficulty understanding or recognising the steps involved

7. Reasoning

thinking is often rigid and concrete
tendency to take things literally

8. Self monitoring

poor use of feedback and breaking rules
not picking up on cues

9. Insight

unaware of own limitations
unrealistic goals or expectations

The information provided here is a guide and doesn’t reflect hard and fast divisions. For example, a person having difficulty learning new information may have a poor memory and/or attention deficits or poor organisational skills.

Each individual is likely to show a different pattern of cognitive changes, often combined with some preserved abilities.

Useful strategies

Here is an example of a cognitive change, the problems arising and management strategies that can be used.:

Cognitive and behavioural changes	Problems arising	Management strategies
Speed of information processing	taking longer to complete tasks unable to keep track of lengthy conversations and instructions	make allowances and give the person extra time present information slowly present information in chunks present one thing at a time check that the person is keeping up

MORE EXAMPLES: Cognitive changes . . . Problems arising . . . Management strategies

Cognitive and behavioural changes	Problems arising	Management strategies
Attention and Concentration	have difficulty concentrating being distractible finding it hard to cope with more than one thing at once getting bored quickly switch off and appear not to listen not remembering what others have said not completing things they start changing the subject often	reduce distractions (e.g. noise, other people) use short, simple sentences encourage the person to stay with the activity for longer periods change activities when necessary when distracted, interrupt and bring back to task give reminders of next step keep to a routine
Speed of information processing	taking longer to complete tasks unable to keep track of lengthy conversations and instructions	make allowances and give the person extra time present information slowly present information in chunks present one thing at a time check that the person is keeping up
Fatigue	having an overall reduced ability to cope getting irritable and distressed having other problems exacerbated	encourage the person to take rest breaks schedule more demanding tasks when the person is at their best (often mornings)
Memory	finding it hard to remember new things forgetting appointments forgetting things people say frequently losing things	give reminders repeat information when necessary encourage person to rehearse and repeat information encourage use of external reminders, i.e. diaries, post-it notes structure a routine by breaking tasks into small steps keep belongings in regular places
Problem solving	reduced ability to find solutions to problems	train the person to approach new tasks in a systematic manner, e.g. break the task into small parts reduce the demands made on the person help educate the family and others about the person's problems avoid giving the person open-ended tasks
Planning and organisation	having difficulty working out the steps involved in a task not considering the end result of their actions having trouble organising their thoughts and explaining things to others	avoid becoming frustrated with the person give prompts for the following steps provide a written list which outlines the steps in order
Rigid and concrete thinking	taking statements literally insensitive and unable to consider feelings of others having a simplistic understanding of emotions being resistant to change keeping doing things incorrectly despite feedback	use simple and direct language, avoid abstract terms avoid using hints or sarcastic humour encourage person to imagine how they would feel in other situations explain any change in routine in advance, giving reasons
Disinhibition	being impulsive and act without thinking of consequences making rash decisions acting inappropriately toward people (including sexually) behaving in a silly, flippant or childish way disclosing personal information too freely	give immediate feedback, briefly asking person to stop behaviour and explain why provide appropriate external controls e.g. over finances remind person of the sensitive nature of some information, giving clear examples ignore the behaviour where possible
Reduced self-control	losing temper quickly being physically/verbally abusive having a lower frustration tolerance	distract or remove the person from anger-provoking situation withdraw attention when appropriate try not to escalate the situation by shouting back identify anger-provoking triggers and avoid when possible
Egocentricity and self-absorption	not considering consequences of their behaviour on others being unable to 'put themselves in someone else's shoes' appearing selfish to others not appreciating carers	try to explain situation from another's or your point of view try not to take offence, understand why the person is like that
Emotional lability	laughing and crying inappropriately changing moods quickly	try to identify triggers which result in mood swings be prepared for changes by having alternative plans
Perseveration	talking about the same topic repeatedly returning to the preferred topic when doing something else	remind person gently they've told you the information before distract the person back to the preferred activity ignore, as much as possible, future references to the topic try not to get into arguments, walk away if you're getting irritated
Reduced insight	being unaware of both cognitive and physical limitations having unrealistic goals, plans and expectations resisting efforts of carer/staff not realising that they have made errors because they haven't checked their work	gently remind person of deficits explain why proposed action is useful, reason through the steps point out possible negative consequences of person's unrealistic plans place external limitations where necessary (e.g. removal of driver's licence/access to car) gradually expose person to reality testing experiences
Poor self monitoring	not realising that they are 'hogging' conversations being verbose and keep talking when others are no longer interested	encourage them to check over their work use signals, agreed in advance, to let them know they're talking too much encourage turn-taking in conversation use external aids, e.g. graphs and tables to help the person monitor their behaviour
Reduced social skills	interacting poorly with others because of all the above problems losing their ability to relate well with others not picking up the usual social cues (e.g. looking at watch)	teach specific strategies like maintaining eye contact, asking questions of others, turn taking in conversation try to encourage awareness of others' reactions
Inertia	appearing to have no motivation and seem apathetic not acting until prompted not completing tasks knowing how to do something, but not doing it spontaneously	encourage person to commence activity prompt first step of the task try to find things that are most interesting for the person reward and encourage any self-initiated activity and persistence accept that the person may need less activity to keep them occupied and happy
Restlessness	complaining of boredom and be restless and agitated	remind person of activities they usually enjoy promote physical activity which may expend some energy