Thinking Skills

One of the most basic functions of the brain is to control arousal. Arousal refers to a person’s level of wakefulness.

Low arousal

At the lowest levels of arousal, there is little or no response to stimulation. For example, if the person is pinched on the cheek, they may not move or even grimace to the pain. The more aroused person may say “Ouch!” and move their face away when pinched.

High arousal

The amount of arousal depends on the type, location and severity of a person’s brain injury. Arousal levels may change during the course of the day, such as more awake in the morning and more tired in the afternoon, and over the course of recovery.

There are varying degrees of arousal. Some people appear very sleepy while others are nearly completely awake. It is important to realize that decreased arousal does not mean a person is sleepy.

Medications for arousal

Doctors may suggest medications to help improve arousal. The type and amount of medicine will vary depending on the person’s specific needs. One class of medicine is called a neuro-stimulant. These medicines have typically been used to treat children with hyperactivity; however, because they also affect poor attention, distraction, disorganization, impulsive behavior, fatigue, and apathy, they are often given to persons with brain injury. These medicines work because they increase the levels of a chemical in the brain called dopamine. Dopamine is thought to improve levels of arousal and cognition. Common brand names include Ritalin, Provigil, and Cylert.

Other medicines that work to increase the dopamine levels in the brain are called dopaminergic agonists. This class of medicine is often given to persons in coma or who have low levels of responsiveness, in an effort to shorten the coma and improve functioning. Common names include Parlodel and Amantadine.

Regulating environment

When a person is in decreased levels of consciousness, they do not respond to all the sensations that are perceived by someone who is fully alert. Therapists working with the person will educate you on how to regulate the environment to gradually introduce different sensory inputs to help with increasing alertness. For example, playing one’s favorite music if the person is fully rested may show changes in arousal. Allowing for plenty of quiet time and rest and then adding only one sensory input at a time so as not to lose the effect.

The ability to pay attention to a task is very important. If there is a problem paying attention, things like school, work, and rehabilitation will likely be affected. For example, if a person is at work and cannot finish the job or only finishes part of the job each day, they will likely be asked to leave that job.

Also, if at home and preparing a meal, it is important to pay attention to the stove to prevent a fire. Paying attention to the cooking process means that the person needs to keep track of how long food is cooking and when it is time to shut off the stove.

Distractions

Sometimes paying attention is affected by distractions. For example, while preparing a meal, the telephone rings. The person may begin to talk on the phone and then forget about the food on the stove. Having a brain injury can make a person more susceptible to distraction. Attention can also be affected by something called hemi-spatial neglect. This means that a person does not pay attention to a particular side of the body or a certain area in space. This often happens when there is an injury to a parietal lobe of the brain.

For example, I can see my left foot, but I do not pay any attention to it. I may not know that it is my foot. The problem I now have is that I may bump my foot into the door frames because I do not make room for it.

Spatial neglect

Spatial neglect can also be seen in other daily activities. A person can see a whole plate of food but may only eat the food on the right side of the dish. Another example is that a person may only put clothes on the right side of the body or put make up on one side of the face. Attention is not paid to whatever object or task is in the neglected area.

Memory is almost always affected to some degree after a brain injury. A very common problem is related to a person’s recent memory. Recent memory is a type of memory which focuses on remembering something that occurred in the last few minutes or hours. It can also be described as memory related to new learning since the brain injury. Some examples of this include difficulty remembering recent things or how to perform a task learned an hour ago. Often, new activities related to the injury, such as using a catheter or special bathroom equipment, can be difficult to remember.

Memories from a long time ago such as from childhood are almost always preserved. This type of memory is referred to as remote memory and refers to information that occurred before the brain injury.

Here are some ways to help with memory issues:

• Provide structure to each and every day.
• Do the same things at the same time each day. Create routines to avoid having to remember what to do next.
• Place a schedule in appropriate rooms, and use step-by-step instructions in the schedule, if necessary.
  • In the bathroom, place a list on the mirror with reminders to brush teeth, take a shower, wash hair, style hair, get dressed, etc.
  • Place a schedule as above in the kitchen. The schedule may include making breakfast, turning off the coffee pot, washing the dishes, taking medicines, etc.
• Keep a memory notebook or calendar to remember appointments, important phone calls and emergency contacts with phone numbers.
• Encourage quiet times during the day, especially when needing to think or plan for the next day. This will cut down on distractions.
• Write notes to yourself or have others write notes for you about things to remember later. For example, you may want to ask your doctor something at your next doctor appointment.  Write down your question on that date in your planner so on the day you go to the doctor, the question will be there right in front of you when you need it.
• Don’t over-stress yourself.
• Rest when needed. You are learning to think and remember all over again. It is hard work and often a mental rest is needed.
• Allow others to help you plan. Accept help from your friends and loved ones.
• Play games like “Memory,” card games, jigsaw puzzles etc. Let learning be fun. Do so in moderation.

Problem-solving and reasoning are very complex skills. A person must think about many things at one time. For example, there are many things that need to be done while making a left turn on a busy street. You need to pay attention to traffic, look out for people walking and notice the color of the traffic light all at the same time before deciding that it is safe to make a left turn. You may even be talking with another person in the car. Without knowing, you are receiving information and making a decision with many distractions taking place, sequencing tasks, and reasoning in a matter of seconds.

Problem-solving requires many skills, including memory, concentration, and perception. If there are other problems with cognition, then problem-solving and reasoning abilities will also be affected.

A person with a brain injury may have problems in some or all of the areas listed above. Problem areas may also range from minor to severe. This will depend on the person’s type, location and extent of injury. Because thinking affects all aspects of life from getting dressed to balancing a checkbook, many of the issues facing persons with brain injury stem from problems in this area. Therefore, much of the recovery process focuses on ways to improve cognition.

Here are some ways to help with problem-solving and reasoning skills:

• Always consider safety first.
• Start with small problems first.
• Accept help from others. Maybe you can do pretend problem games with a loved one. For example, have a friend ask you, “What would you do if (topic) happened?” Together the two of you could practice making good decisions.
• Keep as much structure in your day as possible. This way, if a problem does arise, you will have the mental energy to look at it carefully since the rest of the day is fairly well planned.
• Tackle a problem one step at a time. Ask for help if you are not sure.
  • Step 1: Identify the problem.
  • Step 2: Decide what you need to know about it to make a good decision.
  • Step 3: Gather the necessary information.
  • Step 4: Weigh your options.
  • Step 5: Decide on the best solution.
  • Step 6: Evaluate how it turned out.

The rehabilitation team will conduct cognition assessments with the person recovering from brain injury. Here we provide information about two highly regarded and widely used assessment tools.

Glasgow Coma Scale

The Glasgow Coma Scale measures visual, verbal, and motor skills to access cognitive function after brain injury.

Rancho Los Amigos Levels of Cognitive Functioning Scale

The Rancho Los Amigos Levels of Cognitive Functioning Scale (Revised Version) outlines functional abilities with related levels of required care across 10 levels.

• Level 1 | No response: Total assistance
  • Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli
• Level 2 | Generalized response: Total assistance
  • Demonstrates generalized reflex response to painful stimuli
  • Responds to repeated auditory stimuli with increased or decreased activity
  • Responds to external stimuli with physiological changes generalized, gross body movement, and/or not purposeful vocalization
  • Responses noted above may be same regardless of type and location of stimulation.
  • Responses may be significantly delayed.
• Level 3 | Localized response: Total assistance
  • Demonstrates withdrawal or vocalization to painful stimuli
  • Turns toward or away from auditory stimuli
  • Blinks when strong light crosses visual field
  • Follows moving object passes within visual field
  • Responds to discomfort by pulling tubes or restraints
  • Responds inconsistently to simple commands
  • Responds directly related to type of stimulus
  • May respond to some persons, especially family and friends, but not to others
• Level 4 | Confused/agitated: Maximal assistance
  • Alert and in heightened state of activity
  • Purposeful attempts to remove restraints or tubes or crawl out of bed
  • May perform motor activities such as sitting, reaching, and walking, but without any apparent purpose or upon another’s request
  • Very brief and usually non-purposeful moments of sustained alternatives and divided attention
  • Absent short-term memory
  • May cry out or scream out of proportion to stimulus even after its removal
  • May exhibit aggressive or flight behavior
  • Mood may swing from euphoric to hostile with no apparent relationship to environmental events
  • Unable to cooperate with treatment efforts
  • Verbalizations are frequently incoherent and/or inappropriate to activity or environment.
• Level 5 | Confused, inappropriate, non-agitated: Maximal assistance
  • Alert, not agitated but may wander randomly or with a vague intention of going home
  • May become agitated in response to external stimulation and/or lack of environmental structure
  • Not oriented to person, place, or time
  • Frequent brief periods of non-purposeful, sustained attention
  • Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
  • Absent goal-directed, problem-solving, self-monitoring behavior
  • Often demonstrates inappropriate use of objects without external direction
  • May be able to perform previously learned tasks when structured and cues provided
  • Unable to learn new information
  • Able to respond appropriately to simple commands fairly consistently with external structures and cues
  • Responses to simple commands without external structure are random and non-purposeful in relation to command
  • Able to converse on a social, automatic level for brief periods of time when provided external structure and cues
  • Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.
• Level 6 | Confused, appropriate: Moderate assistance
  • Inconsistently oriented to person, time, and place
  • Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection
  • Remote memory has more depth and detail than recent memory
  • Vague recognition of some staff
  • Able to use assistive memory aide with maximum assistance
  • Emerging awareness of appropriate response to self, family, and basic needs
  • Moderate assist to problem solve barriers to task completion
  • Supervised for old learning, such as self-care
  • Shows carry over for relearned familiar tasks, such as self-care
  • Maximum assistance for new learning with little or no carry over
  • Unaware of impairments, disabilities, and safety risks
  • Consistently follows simple directions
  • Verbal expressions are appropriate in highly familiar and structured situations.
• Level 7 | Automatic, appropriate: Minimal assistance for daily living skills
  • Consistently oriented to person and place, within highly familiar environments
  • Moderate assistance for orientation to time
  • Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks
  • Minimal supervision for new learning
  • Demonstrates carry over of new learning
  • Initiates and carries out step to complete familiar personal and household routine but has shallow recall of what they have been doing
  • Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance
  • Superficial awareness of their condition but unaware of specific impairments and disabilities and the limits these place on their ability to safely, accurately and completely carry out their household, community, work, and leisure ADLs
  • Minimal supervision for safety in routine home and community activities
  • Unrealistic planning for the future
  • Unable to think about consequences of a decision or action
  • Overestimates abilities
  • Unaware of others’ needs and feelings
  • Oppositional/uncooperative
  • Unable to recognize inappropriate social interaction behavior
• Level 8 | Purposeful, appropriate: Stand-by assistance
  • Consistently oriented to person, place, and time
  • Independently attends to and completes familiar tasks for 1 hour in distracting environments
  • Able to recall and integrate past and recent events
  • Uses assistive memory devices to recall daily schedule, to-do lists, and record critical information for later use with stand-by assistance
  • Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance
  • Requires no assistance once new tasks and activities are learned
  • Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action
  • Thinks about consequences of a decision or action with minimal assistance
  • Overestimates or underestimates abilities
  • Acknowledges others’ needs and feelings and responds appropriately with minimal assistance
  • Depressed
  • Irritable
  • Low frustration tolerance and easily angered
  • Argumentative
  • Self-centered
  • Uncharacteristically dependent or independent
  • Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance
• Level 9 | Purposeful, appropriate: Stand-by assistance
  • Independently shifts back and forth between tasks and completes them accurately for at least 2 consecutive hours
  • Uses assistive memory devices to recall daily schedule, to-do lists and record critical information for later use with assistance when requested
  • Initiates and carries out steps to complete familiar personal, household, work, and leisure tasks independently and unfamiliar personal, household, work, and leisure tasks with assistance when
    requested
  • Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action, but requires standby assistance to anticipate a problem before it occurs and take action to avoid it
  • Able to think about consequences of decisions or actions with assistance when requested
  • Accurately estimates abilities but requires stand-by assistance to adjust to task demands
  • Acknowledges others’ needs and feelings and responds appropriately with stand-by assistance
  • Depression may continue.
  • May be easily irritable
  • May have low frustration tolerance
  • Able to self-monitor appropriateness of social interaction with stand-by assistance
• Level 10 | Purposeful, appropriate: Modified independent
  • Able to handle multiple tasks simultaneously in all environments but may require periodic breaks
  • Able to independently procure, create, and maintain own assistive memory devices
  • Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work, and leisure tasks, but may require more than usual amount of time and/or compensatory
    strategies to complete them
  • Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur, but may require more than usual amount of time and/or compensatory strategies
  • Able to independently think about consequences of decisions or actions, but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action
  • Accurately estimates abilities and independently adjusts to task demands
  • Able to recognize the needs and feelings of others and automatically respond in appropriate manner
  • Periodic periods of depression may occur.
  • Irritability and low frustration tolerance when sick, fatigued, and/or under emotional stress
  • Social interaction behavior is consistently appropriate.