I wake up feeling confused. I look around, this is my room but something doesn’t feel right. The calendar on the wall tells me it’s the 31st of July, a Sunday in 2016.
Why can’t I remember anything? I’m scared, I feel lost and alone. (I reach for the phone). It’s 10:30 in the morning, somehow it’s 2016 but I can’t remember what I did yesterday or last week or last year! I thought it’s 2014. (I can see my wife walking towards me. Okay, so this isn’t a dream.) She’s helping me sit up, why can’t I move on my own, why do I need her help. I can see the news play out on TV but why is he speaking so fast? I can’t seem to understand…Why don’t I know what day it is? I try to move my legs but I can’t, I need her help. I’m scared, I’m angry. Oh! the news is on. What day is it today?
-The Disoriented Mind
Disorientation is often the most unsettling result of a traumatic brain injury (TBI). Losing the concept of time and place can make simple, everyday scenarios like getting out of bed every morning a mammoth task. Any activity can become a nerve racking and frustrating experience. What once came so effortlessly is now, filled with fear and anxiety. The cognitive implications of TBI are a scary reality, and it doesn’t end at disorientation.
Simply put, cognition is the act of knowing or thinking. An individual’s cognitive capacity is the system that guides them through life. We use cognition when we learn something, solve problems, communicate with others, pay attention to tasks, remember information or understand others and our environment.
So which activity from your day do you think is an example of using your cognitive skills?
The answer is: almost all. Cognition facilitates activities like engaging in conversations, driving a car, remembering a name and even playing football or making a cup of tea. In fact, you are using the cognitive skills of working memory, attention, learning and language while you read this article! Cognition is the ubiquitous entity that guides each activity through the day.
Every year around 1.6 million Indians become neurologically disabled because of TBI. Keeping this in mind, it’s important to understand a few things about cognitive impairments due to TBI:
Not only does the extent of cognitive impairment depend on the physical damage but it is also influenced by the person’s pre-injury abilities and personality.
AR, was a bright, active and determined student. At 14, she suffered a traumatic brain injury due to a road accident. The accident changed her. Despite being able to return to school after a year, she became slow at grasping concepts and was easily distracted, but her determination remained strong and helped her achieve greater goals through rehabilitation.
The most common disturbances after any TBI usually involve attention, concentration and memory skills. Memory and attention disturbances can be particularly problematic since these two functions are the foundation for most other cognitive functions. For example, while you’re reading a novel, you certainly need to pay attention to the current page but you also need to remember the past chapters in order to maintain the flow of context. Take a moment to think of any task that does not involve attention or memory.
AR found it difficult to hold conversations with people, and would often be repeating the same phrases, struggling to maintain a flow in conversation. She would frequently forget the names of people whose faces were so familiar to her. These small things greatly affected a teenager’s social life, and it was, and still is, important for people around her to have patience and empathy while conversing with her.
The executive functions are considered the CEO of the brain. They include skills like organizing, planning, mental flexibility, working memory or decision-making. These functions help the brain organize incoming information, process this information, and take necessary action based on it. Therefore, these skills are necessary to help individuals organize, remember, prioritize and start working on tasks. So, for example, organizing a dinner party, deciding on the best route to reach the office or planning your Sunday, all involve the executive functions. In 2015, TD, a 61-year old doctor was involved in a car accident and suffered a moderate TBI which affected several cortical and subcortical regions of his brain. After a year, Dr. TD finds it difficult to keep up with discussions with his family or friends. He has become very slow in understanding, processing and responding to conversations and can only manage one-on-one interactions. Moreover, he experiences significant difficulty to start any new task or plan his day. Dr. TD, who could previously incorporate information from a variety of sources when making treatment-related decision for his patients, now misses intermediary steps such as, forgetting to add milk while making masala chai.
Language functioning can also be affected depending on where in the brain the injury has occurred. Certain brain injuries can result in difficulty coordinating thoughts to produce speech or comprehending what others are saying.
TD often confuses names of objects and on several instances; he has called the ‘door’ a ‘window’ or the ‘microwave’ a ‘fridge’. In general, he isn’t able to easily recall names of things and ends up describing them instead. He takes a few seconds to think before he can respond to a question anyone asks.
How were AR and TD helped? A comprehensive plan of action was created based on the results of their detailed neuropsychological evaluation. This detailed evaluation assessed all their cognitive functions. The plan usually involves two processes:
Remediation – to restore the internal mechanisms of impaired cognitive functions in the brain.
Compensation – to learn external strategies to compensate for permanently impaired functions.
AR has now been undergoing rehabilitation for two years. She isn’t the same person she used to be before her unfortunate accident, but she has improved a great deal through the rehabilitation process. She interacts with her friends, has developed new hobbies and has started attending school albeit, for fewer hours. She is learning techniques to compensate for the lasting deficits and is working to overcome the ones she can. Despite TD’s injury being so recent, he and his family have observed significant improvement as they continue to work hard through the rehabilitation process.
TBI can be quite disabling. Often times, it requires the individual to relearn the basics all over again, and cope with the reality of the disability. Neuropsychological rehabilitation is necessary to treat and overcome the various problems that arise after TBI.
Previous Article: “Invisible Wounds of TBI” https://www.facebook.com/notes/synapsium/invisible-wounds-of-traumatic-brain-injury/590010201159510
The upcoming articles will focus on ‘brain injury in India’ and ‘the process of neuropsychological rehabilitation’.
Authorship ‘Life with an Injured Brain’ is written by Rahat Sanghvi, for Synapsium Brain Health Clinic, Mumbai. Shraddha Shah founded Synapsium Brain Health Clinic in 2013 where a team of psychologists work to provide various neuropsychological and psychological services. Shraddha is a clinical psychologist specializing in neuropsychology. She is currently serving as a private consultant at Jaslok Hospital & Research Center and Sir H.N. Reliance Foundation Hospital. She is also a visiting faculty member at S.N.D.T. University. Shraddha trained in Neuropsychological Rehabilitation under renowned neuropsychologist, Dr. Barbara Wilson and her team from United Kingdom. She has also received training and experience in Neurorehabilitation as an intern at the well-known Rusk Institute of Rehabilitation, New York.
