What needs a cognitive strategy? What needs to be compensated for :
First, on what gives the patient the most frequent grief based on symptomatology of neurological insult
1. fatigue and
2. being overwhelmed with information coming too quickly, slowed information processing, leading to dysphoric affect (catastrophic reaction, i.e. anger, tears, flight, freezing, confusion, helpless laughter).
Secondly, link the performance of a compensation or device use to either:
1. dysphoric affect (catastrophic reaction) or
2. a physiological response to increase generalization
One source of “personality change” is how family perceives the patient.
When questioned about how their loved one has changed in personality after acquired brain injury, family members mention anger and fatigue as the sources of “personality change” after ABI.
Zeiner, HK. Living with TBI: Impact on the Survivor and Their Family in Traumatic Brain Injury , Independent Study Course, Veterans Health Initiative: Traumatic Brain Injury, Department of Veterans Affairs, Employee Education System, p. 99-112, October 2003
The optimal condition for rehabilitation of neurologically impaired patients is created when the patient, family and staff are allied against “demon” brain injury. This is the triangulation necessary for optimum recovery.
For those with brain injury, “resilience“ is defined as “I use the latest/best compensation most effectively.
This redefines life from “be the best you can be” into, “I cope effectively but not perfectly, to all that I encounter”.
To Get Change With a Cognitive Strategy, You Have to Have Three Parts to the Cognitive Construct 1.What is the specific problem (closely related to a basic unit of brain function) 2.What you have to do to correct the specific problem 3. Both must be learned by the Patient
Dependency- When the Survivor Can But Doesn’t Do Something . Think of the survivor’s brain as Swiss cheese. There is plenty of good cheese — intact circuits that were unaffected by the injury. But now there are a few “holes” where cells were injured or destroyed.
Management Strategy Disturbed Sleep/Wake Cycle. In addition to medication, the treatment for sleep cycle disruption is to artificially impose a rigid bedtime and rise time on the patient. Choose a total sleep time, which is 1 to 1.5 hours longer than the patient’s pre-morbid length of sleep at night. Patients must go to bed at a set bedtime, whether or not they fall asleep. They need to rise at a set rise time and not nap during the next day, even if very tired.
It takes about 3 weeks to establish a new artificial day/night cycle. It must be applied 7 days/week. After the three weeks, patients can be allowed afternoon naps, but the schedule must be maintained. If the artificial pattern is broken, it always takes about three weeks to re-establish again.
All thinking requires some expenditure of mental energy.
Cognitions such as:
switching attentional focus to a new person,
keeping up with the topic of conversation,
organizing an answer to a question,
making a decision,
trying to decide what to do next,
organizing your day’s activities in the morning
All cost mental energy.
Many of the cognitive functions, which are automatic and reflexive for people without BI, require 2-3 times the mental effort to accomplish for people with BI. This is due to the fact that people with BI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.
• Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the days with scheduled activities, do one important thing/day
How to Compensate for the Symptom of Fatigue. • Make important decisions when the person has the greatest amount of mental energy, usually in the morning. Schedule patients with BI in the morning. • Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the your day with scheduled activities. Do one important thing/day • The use of an organizer, either written, taped or electronic is essential.
Problems With Sequencing: Every activity has a beginning, middle and an end. Sometimes, people with BI drop off the “end” response. They begin, do the middle, then begin something else, do the middle, then begin something else, etc. By the end of the day-they have been busy, but they completed nothing.
When learning a new task, pay attention to how many steps the survivor can easily learn at once. Break multi-step tasks into groups of 2 or three steps. Over learn those before moving on to the next 2 steps.
Inability to read complex social situations visually
Inability to negotiate (de-centering and multi-track)
Line between inside thought/outside thought has moved. (Gumballing)
Age of injury/insult precluded learning some social schema (Shank and Abelson)
Trouble Reading Other’s Emotions Because I have trouble (spatially) reading other peoples faces, I need to ask how they are feeling to read them correctly. Make like a psychologist and sprinkle your speech with “So how do you feel about that?”
State the other persons main point. What do they want?
State your point. What do you want?
State a sentence which includes half of what they want and half of what you want.
Social Compensation’s Caretaking spouses often feel unappreciated for their extraordinary efforts. Writing a couple of phrases of appreciation “You are such a wonderful partner, I’m so lucky to have you”. Or “Have I told you I love you?” in the patient’s memory book or electronic organizer every few days, (which the patient reviews after each meal) can make a spouse feel that their efforts are noticed.