One day at a time. Cognition and Caregiving after a TBI.

One day at a time. Cognition and Caregiving after a TBI.


By Bill Herrin


Better cognition takes time

Thinking comes so naturally that most people take it for granted, but after a traumatic brain injury – many times, thinking can be more of a deliberate action. It takes focus and effort to put a series of thoughts together after TBI, to speak clearly, or to even move. Simply put, the brain (like the body) takes time to heal. Since no two brain injuries are identical, there is no clear path to better cognition. There are, however, certain broad directives that can get you moving in the right direction in most situations. The hardest part of this is to accept your “new normal”. Acceptance, once you come to terms with it, gives you the desire to work toward the goal of better cognition, coordination, memory, anger management, judgement, attention, and other challenges. Once you accept your situation isn’t going to change overnight, you can start the process of healing, along with testing your limitations. Although finding your limitations is difficult, knowing what they are is a huge step towards improvement in areas that need changing. When a person lacks enough cognition to be self-aware or to strive towards improvement, that’s a test for the caregiver’s guidance and patience. Sometimes just being there for your friend, spouse, or loved one is all you can do.

As a caregiver, high expectations from a TBI survivor shouldn’t be overly discouraged, as they can bring progress through their desire to improve. They may not reach the goal they wanted to, but they’ll make strides towards it! That is positivity in its purest form. Nobody wants to be working through such a huge change in their life without encouragement – cheer them onward and upward! Even if they fail, they are trying, and that shows initiative. Their desire to improve should never be underappreciated.

Change after TBI is incremental

When cognition is in the early stages of improvement, the changes may be noticed more by the family or caregiver than they are by the survivor. Sometimes incremental change is just too subtle for survivors to realize, but pointing out the changes to them is incredibly positive reinforcement. The following tips on cognition are excerpted from Lash & Associates’ tip card titled “Cognition – Compensatory strategies after brain injury”

Cognitive fatigue is one of the most common consequences of brain injury. The survivor’s brain is simply working harder to think and learn. Cognitive rest is just as important – maybe even more important – as physical rest after the brain has been injured. Cognitive fatigue can have a ripple effect. You may have a shorter temper, find it harder to concentrate, make more errors, misplace things or forget appointments. You may feel like you can’t think straight no matter how hard you try. Many survivors describe cognitive fatigue as “hitting the wall”.

Do you…

• Feel tired after mental exertion?

• Have a harder time thinking after working on longer or more complex tasks?

• Need more sleep than usual?

• Find it hard to get through the day without napping?


Tips on compensatory strategies…

• Take breaks.

• Schedule rest periods.

• Stay organized.

• Use a daily planner.

• Use time management strategies.

• Eat nutritious meals on a regular schedule.

• Go to bed at a consistent time.

– Create a weekly exercise routine.

• Request a medical evaluation.

• Discuss medications that may help with a physician specializing in brain injury rehabilitation.

There are a plenty of great suggestions for compensatory strategies for survivors and their caregivers in the tip card referenced above. Here’s a link to it here!


When it comes to cognitive functional rehabilitation – seek professional advice first (of course), but when the TBI survivor is at home with a caregiver, clinician, friend or family member, there are some great approaches to working on communication, social interaction, organization, reading, attention, problem solving, and rebuilding other deficits through consistent application by any or all of the people involved in the care of the TBI survivor.

Referencing the book titled “Cognition Functional Rehabilitation Activities Manual” (Developed by Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC-SLP/L), I’m sharing an excerpt that provides a glimpse into the workbook’s approach to helping a person with cognitive challenges. Many of the exercises use interaction and documentation to assess where the TBI survivor is at (cognitively speaking) on an ongoing basis. Remember, this is a workbook, and there are plenty of exercises that build activities and responses ongoing. Here is the example of how the manual challenges a TBI survivor with structured and specific activities:

Task: Provide awareness training.


  1. Prompt participant to work on awareness training.
  2. Ask why participant is here receiving rehabilitation.
  3. Ask what skills/activities are harder since the brain injury.
  4. Ask what participant does to compensate for these difficulties and which therapies address them.Ask what participant’s strengths are (what is participant good at?).
  1. Ask the participant how the brain injury and difficulties affect daily activities.
  2. Provide answers and examples when needed.
  3. Provide positive reinforcement for strengths, being receptive to information regarding brain injury, for participating in the task, and for being motivated to participate in rehabilitation.

Staff Reminder: (clinician, caregivers, family, etc.)

Provide a complete description of this activity in the Functional Rehabilitation Documentation Form.

Last words…

Finding cognitive deficits is the first step

By asking specific questions, and recording the corresponding answers, this workbook is a great tool for tracking progress – and the exercises can be done more than once, to check and see how/if the answers have changed. So, what’s the takeaway from this excerpt? It illustrates that structure and consistency of care and treatment by family/caregivers and professionals can overlap and create a solid overview of cognitive deficits, and improvements.

In closing, the main goal of this post is to address the expectations of TBI survivors and their caregivers, to encourage them to strive for progress and to offer resources for compensatory strategies, and cognitive rehabilitation. If all parties work in tandem with the common goal of helping a TBI survivor make it to the next level, they’re all closer to the goal…and the whole team wins. That’s the goal!

3 responses to “One day at a time. Cognition and Caregiving after a TBI.”

  1. Jessica says:

    Congrats on you achievements. As a lady who was born in Ireland, I love that you choose Irish jigs to play on your violin.
    I sustained a life-threatening head injury after falling head-first down a flight of stairs in Toronto, 1969. My head struck a 12″ steel-plated door at the bottom of the steps rendering me in coma and semi-coma for 2 weeks.
    There was no cat-scan or M R I at TO hospital then, so my injury was diagnosed as’ severe ‘concussion’ not severe brain-injury!. Yet I had a 5″ cut on the right side of my skull, a hemorrhage behind my right eye, which led to a horrifying and frightening protruding eye for some time.

    I fought against the odds as I became a child in the body of an adult. Along with having a drastically changed personality, I had to learn just about everything all over again for 16 + years. Fortunately I survived suicide as I had two beautiful young daughters to consider. The Irish in me also helped as I became determined to survive and planned an unorthodox way of self-healing while getting myself off all medications.

    I did brain-stimulation by writing sentences, poems and memorizing them. At first I could only memorize three words. I never got as far as memorizing a whole sentence if it was too long however! The practice however was beneficial. I then went to library research rooms to look up words I did not understand in the books I was reading. I made the research room a second home and learnt as much as possible about life in general. I know I was to pick on some subject in order to do some research on it. This led to my 20 year research on ‘the science of the supernatural’, generally known in the West as ‘Theology.’

    I want A B I survivors to know that my dormant brain cells were decidedly woken up from the intensity and duration of such research and even more stimulation took place from the writing of my memoir “From Tragedy to Triumph: Journey Back from the Edge” ( I have also completed a 22 chapter story based on my research entitled ‘Jewels in the Mud: A Search for Spiritual Meaning’ which I hope to get conventionally published.

    Happily, lives have been saved as a result of my memoir, now in the hands of an actor who sees it as a screen-film or T V mini. A screenplay has been written for that purpose. Having a film made of my story has been a dream for many years as I know how much of an impact it will make regarding brain injury, and depict the trauma of brain- injury and how survivors suffer in silence as I myself did. Fortunately there is a lot of comedy in my story which creates a nice balance re tragedy and humor! To all those who have suffered brain injury I say ‘Never limit yourself and never allow others to limit you” Love and Light to you all.

  2. I had a severe motorbike accident in 1986 that left me in a deep coma for 5 months. I’ve since achieved 2 degrees and a diploma in the Humanities. I experienced many problems – cognitive fatigue being one of them. One thing I learned though is that “… the longest journey begins with the first step”.

  3. Kitt McComb says:

    Thank you very much for your excellent article.

    I remember after my injury, sitting down to dinner, picking up a fork and knife and just looking at them, then at my plate, then at my husband.

    I remember picking up a pen to write something and just staring at the paper, waiting for the tip to move. But nothing was reaching my hand. After the initial movement, I went blank.

    Eventually, I regained these skills. Believe it or not, I laughed at the wall, the mess going on, the short circuiting. “This is so silly,” I said to my husband. “Can you cut my meat?” And he did. Writing? Well, I decided since I couldn’t write in cursive, I would print. Big letters, right out of Kindergarten. “How do you make a ‘y’ again?”

    But time, patience on the part of all, and humor, helped my brain relearn all sorts of things. No, I still can’t read a 200 page book in an afternoon, the way I did before “the injury”. But, at the age of 58, 11 years after my injury, I began playing violin, something I’d always wanted to do. After six months, I’m playing Irish jigs.

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