Thinking & Memory

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 hemispatial 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 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.