INTRODUCTION
Memory problems, fatigue, anxiety, irritability. These are some examples of cognitive symptoms that patients with brain injury may experience. These consequences sometimes appear only months or years after the brain injury.

1.What is COGNITION?
Cognition is a concept from neuropsychology. Cognition involves the brain functions that are necessary for perceiving, thinking, understanding, remembering knowledge and applying knowledge in the right way.

Cognition is divided in the following three types:

• Basic Cognition includes attention, learning, memory, perception, thought and language.
• Metacognition consists of judgment, reasoning power and realism.
• Social Cognition includes emotion, practical language skills and empathy.
  

Cognitive problems occur in areas of knowledge, perceiving and understanding. Difficulties with memory, concentration and thinking speed are the most common.

Cognition is measured by an intelligence test. This measures a total IQ (TIQ). TIQ is divided between a verbal part (VIQ), which focuses on verbal skills and knowledge and a performal section (PIQ), which focuses on action-oriented thinking.

By means of the tests for performal IQ it is determined whether a person can deal with problems in a practical manner. Also motor skills and spatial awareness are investigated.

In people with brain injury very large differences between the VIQ and PIQ may have emerged by the injury. This is called a discordant intelligence profile, Verbal - Performal gap or VIQ PIQ discrepancy.

However, a Verbal - Performal gap can also occur in highly intelligent individuals and in people with autistic disorders. So, a VP gap doesn't have to be the result of brain injury since it can also occur in people without brain injury.

More about the VIQ PIQ discrepancy

That means:

Attention and concentration deficits
Delays in the processing of information (mental slowness / pace)
Impaired intellectual functioning (sometimes only partial)
Memory problems, impaired learning ability
Orientation Problems person, place, time and space
Visual-spatial problems
Problems with coordinating daily and / or complex actions (apraxia)
Problems recognizing things, perceiving
Language problems
Problems with the arithmetic
Problems with executive functions

2.PROBLEMS WITH ATTENTION
    AND CONCENTRATION
 

• Focusing the attention on something (a conversation, an activity, an exercise).

• Retaining the attention to the activity.

• The distribution of the attention. If this is difficult, it is almost impossible to perform simultaneously two or more tastks. For example: talking whilst doing the dishes or making coffee and having a conversation becomes impossible. But also following a conversation with multiple people is difficult.

2.2 NEGLECT

Neglect is a disorder that occurs mainly in a damage in the right hemisphere (with the failure symptoms left). There is no "attention" perception of the affected (usually left) side: people  "ignore" the affected side and the space around it: This side is not seen, not felt or seen.
Neglect can involve all kinds of problems in daily life:

• If someone is sitting on a chair or lying in bed, the crippled arm can still hang down. Injuries can easily arise that are also less noticed by the neglect.

• People often run into things on the affected side (to obstacles, door frame), because that side is not observed.

• 'Ignoring' people on the wrong side often happens. Not out of unwillingness, but because they are not observed.

• When eating, half of the plate is left uneaten, is 'forgotten' to eat.

• Only one half of the face is shaved.

• Only one side of the face is done with make up.

• Car driving, cycling or taking part of traffic is very dangerous because on the affected side objects are not detected. 

• Doors are walked by on the side of neglect, and so someone can get lost.

• In extreme cases, the patient doesn't recognizes his own cripple arm and leg as his own limbs. He feels a strange leg lying in bed.

Drawing of a clock, as seen by a patient with neglect

2.3 MENTAL INERTIA


Many people with brain injury complain that thinking is slower and takes a lot more time and attention. If everything is slower in the head, the outside world seems an accelerated played movie.

It also takes a lot of energy to follow all that. If a lot is said or done at the same time, someone can not take the pace anymore. Mental pursuits such as reading a book or transferring money via the internet, takes a lot of time and can be exhausting. The world is going too fast ...

 
A slower pace in the processing of information is noticeable when the patient responds to a question or command, remarkably with a long time. By that slowed pace, people with brain injuries are more sensitive to time constraints, and they may feel they are running out of time.

Slowed information processing can have a negative influence on other attentional functions (eg when dividing attention), on memory (eg storing information), or the organization and planning of behavior.

2.4 MEMORY PROBLEMS


Remembering new information takes more time than before and the information is often not retained properly.

This also has to do with attention problems and mental sluggishness. Additionally, digging up information from memory is difficult.

 
Furthermore, it happens that people with brain damage do not recognize certain objects or can not remember certain faces.

It is now known that practicing with various memory games hardly changes anything in daily life.

 

By the lack of the ability to generalise (the transfer of training effects in the practice situation to everyday life), the training must always be focused on what one wants to learn.
Forgetting messages, loss of keys, forgetting appointments, and so on, therefore can not be solved by card games and computer training.

 

So memory training do not have the effect that it improves memory. It is not the case that you're automatically going to remember better after a memory training. You learn to remember better through all sorts of memory tricks (strategy training, training compensation).

 

Most memory training include the following: more attention, more time, more repetition, learn to make more connections, learn to think more in pictures (visual support) and organize better and more!

     Attention
     Time
     Repetition
     Associate or Link (connections)
     Visualize (make link images in your memory)
     Organize

A good site about memory training is by neuropsychologist Feri Kovács. Click here:

 

2.5 PROBLEMS WITH ACTING; apraxia

Apraxia is a cognitive disorder by which people can not perform operations properly.

For example, a fork is used for eating soup. A toothbrush is used for combing the hair.
Or operations are reversed; when dressing, the pants are put on first and the underpants over it.

Often acts which consist of several steps are the hardest. Examples include making coffee or make a phonecall.
 
2.6 PROBLEMS WITH ORIENTATION

This means that someone does not knows well what date or time it is, or where he is exactly. The spatial orientation is worse: someone does not know the way home.
    
2.7 PROBLEMS WITH PLANNING AND ORGANIZING

If someone wants to do something, he has to plan. It is not only for difficult tasks only as do the shopping, but also for a simple activity like making phone calls. The ability to plan and organize is often gone after brain injury.


Performing a task might succeed, but than it should be clear what to do exactly. "Are you cooking dinner tonight?" Is much too complex.

'Making dinner' concerns a several sub-tasks: invent a menu, looking for a good  recipe, making a shopping list, going to the store, handling money, cooking dinner, several pots and pans, and ensure this all is ready at a certain time.

2.8 NO UNDERSTANDING of LIMITATIONS

Especially people with brain injuries on the right side of their brains (with failure symptoms on the left side of their body) do have a remarkably poor understanding of their capabilities and limitations.

Someone knows that he has had a stroke, but does not experience the limitations as the environment does. This brings difficulties with the rehabilitation: if someone does not know what is wrong with him, he can not work on it or train it.

For example, some people do not realize that walking is no longer possible without a cane, and then fall. Or someone does not see that driving is dangerous.

2.9 PROBLEMS with UNDERSTANDING spoken and written LANGUAGE

Aphasia is the term for a language disorder. In people with aphasia, the use of the language is disturbed. Speaking, reading and writing may be limited. The concept of what another person says may be impaired.

How the language faculty is affected varies per person. Some people with aphasia can not speak. Others talk incessantly, but are incomprehensible. Still others are only unable to think of the right word.
More subtle is the language disorder in which people no longer understand figurative speech and take everything literally, even sayings.

3. EFFECTS on the AREA of EMOTIONS and CONDUCT

Not only cognitive skills can be affected by brain injury. There are often problems with emotions and behavior. To deal with it is not only difficult for the patient, but also for the environment. Your brains is you! ...

3.1 DEPRESSION

Life can be completely different after brain injury life. This is often difficult to accept. Someone may henceforth need a wheelchair, cannot go home or cannot do his job.

These experiences of loss can lead to a lot of grief, which is similar to mourn. A person may become depressed.

Depression is accompanied by much psychological suffering. But it may also deteriorate physical functioning.
 
 

3.2 Easily overwhelmed by emotions, Easily overstimulated

A common complaint is that people get overstimulated much easier. It is like a healthy person, who not only has to multitask in fifteen tasks, but in doing so, also must drive a car in thick fog with 180 miles an hour, while he must analyze a piece of music for his job, counting the half notes and counterfeit notes, and counting how many quarters notes are inside.

That's impossible .. a person may react agitated. The situation that the kids on the backseat ask a question to you about the year that Charlemagne died ..., while you are driving the car, it will be comparable to the situation of someone with brain injury ... This person is not able to do all the tasks that are demanded and can be easily tempered.

Tears may just flow at the slightest emotion, without feeling the need of crying, which itself often is perceived as a nuisance. Read more about overstimulation.

3.3 DIFFICULTIES IN MANAGING IMPULSES

People may find it difficult to control their impulses. The brake is off. For example, someone swears faster if something fails. He might become unrestrained in eating and snacking, or being uninhibited in sex.

3.4  SHOWING LITTLE INITIATIVE

It is often difficult for the environment if someone takes no more initiative and doest not show interest.
Sometimes this is the result of depression, but it can also be the result of the brain damage itself. It mainly occurs in people with a stroke of the frontal brains. People can also be emotionally very flat.

3.5 LIMITED FLEXIBILITY

After a stroke, people often can not cope with changes very well. If something is not going as expected, they can become quite upset. For example, unexpected visit or a setback are hard to process.

3.6 DEPENDENT BEHAVIOR

Some people are showing more and more dependent behavior to their partner or other relatives. They leaves it to them to do the conversations, to arrange things and doing physical activities. The partner will gradually take over responsibilities increasingly, so the behavior gets worse.

4 FATIGUE AND NEUROFATIGUE

The most common complaint after brain injury is a (severe) fatigue and increased need for sleep. Often it is even the main complaint that people have.
The fatigue is so severe that people are limited in their daily activities and social contacts.
Often the fatigue is a combination of physical and mental fatigue. If the brain's sleep center is also affected, the fatigue is twice as large. Read more

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Sources Foundations of neuropsychology Luria, Attention disorders. A neuropsychological textbook Eling & Brewer, Coping with brain injury Palm, hersenletsel-uitleg.nl, attention, mental speed and executive control after closed head injury, Spikman hersenstichting.nl, Cognitive psychology Neisser, New York City, MT Banich (2004). Cognitive Neuroscience and Neuropsychology. 2nd edition. Houghton Mifflin Cie and J.B.M. Kuks, J. W. Pike, H.J.G.H. Oosterhuis. Clinical Neurology 15th Esodition, Bohn Stafleu Of Loghum, Wood, 2003, ISBN 90-313-4028-6