Cognitive rehabilitation after brain injury: memory, attention and executive function

Cognition is the set of mental processes that let us think, learn and remember. After a stroke, a head injury, a brain tumour or an infection of the brain, any of these skills can be affected, and the changes are often invisible to other people. Headway describes the result as feeling that life is lived in the slow lane, and notes that quality of life and sense of identity can suffer.

In the NHS the work is usually led or overseen by a clinical neuropsychologist or another psychologist with brain injury experience, working with occupational therapists and speech and language therapists. They begin by talking to the person and the family, then use specialist tests together with practical observation of everyday tasks. NICE guideline NG252 asks teams to combine standard tests with functional assessments, because someone can score well in a quiet clinic room and still struggle in a busy kitchen.

• Orientation and processing speed.

• Visual, spatial and perceptual skills.

• Language and communication.

• Attention and working memory.

• Learning and memory.

• Executive function, meaning planning, flexibility and self-monitoring.

• Social cognition, such as reading other people's emotions.

Memory is not one skill. Headway explains that people with amnesia typically keep near-normal immediate memory, so they can repeat a number straight back, but struggle after a delay or distraction and have trouble learning new things. Skills practised for years, such as driving or playing an instrument, are usually kept, and cues such as the first letter of a name can help retrieval. Memory for events just before the injury is often patchy, while older memories are generally better preserved.

Stroke rehabilitation guidance from NICE lists the approaches teams use. They include raising the person's own awareness of the memory problem, errorless learning, where the person is stopped from making mistakes that could be learned by accident, and elaborative techniques such as making associations or using mnemonics. External aids, such as diaries, lists, calendars, alarms and smartphone reminders, and environmental strategies, such as fixed routines and labels, are part of almost every plan.

Practical details matter. A diary only works if it is the single place for appointments and is checked at fixed times, so therapists usually rehearse the habit with the person rather than just handing over the equipment.

Attention problems show up as difficulty following a conversation in a noisy room, losing the thread of a task or taking longer to answer questions. Information may be hard to focus on or process when there is background noise, bright light or a crowd, as in a supermarket.

NICE suggests teams consider attention training for people with attention deficits after stroke, and that everyday tasks are adapted: minimising distractions, breaking tasks into steps and giving prompts linked to the task. Pacing matters here as well, because concentration is one of the first things to fail when fatigue builds.

Executive function relies heavily on the frontal lobes, which sit behind the forehead and are especially exposed in traumatic injury. When they are damaged, people may struggle to start tasks, plan ahead, solve problems, adapt when plans change or control impulses. Because motivation can fall, others sometimes mistake the problem for laziness.

Headway sets out coping approaches that therapists will often adapt. Lists placed where they will be seen, alarms to prompt a start, and rewards for completing a task help with initiation. Filing systems, a single place for keys and phone, and weekly routines help organisation. For flexible thinking, back-up plans written in advance and breaking a big job into stages help. For multi-step jobs such as cooking, a regular pause to ask "what am I doing, and where am I up to?" can keep the sequence on track.

• Internal strategies, such as self-talk and mental rehearsal, are taught alongside external ones.

• Changes to the environment, such as fewer distractions or a tidy fixed workspace, reduce the executive load.

• Family and carers are shown the strategies so support continues outside therapy sessions.

Some people do not recognise the changes in their thinking. Headway calls this lacking insight, and notes it can leave a person vulnerable if risks are not recognised. NICE therefore says teams should help people and families build understanding of cognitive difficulties, and support adjustment before or alongside rehabilitation. Pushing strategies on someone who does not yet accept they are needed rarely works.

Emotional disturbance, including low mood, anxiety and psychological trauma, can depress cognitive performance, so a combined assessment of cognition, mood and behaviour is recommended where a neuropsychological assessment is done. Treating depression or poor sleep sometimes improves day-to-day thinking more than any cognitive exercise.

The usual route is through the GP, the neurologist or the rehabilitation team that already knows the person, who can refer to a clinical neuropsychologist. After a stroke the NHS describes a home recovery plan that can include activities to improve memory, concentration, thinking and mood, with a review of progress at about six months.

Availability varies between areas, and community neurorehabilitation teams may offer a time-limited block of sessions rather than open-ended therapy. NICE asks services to plan for later review and for how the person can re-enter the service if needs change.

NICE advises rehabilitation teams to give general advice on keeping the brain active, such as taking up new hobbies, getting out to socialise and playing games or puzzles, and to address risk factors for cognitive decline including physical activity, smoking, blood pressure control and sleep. Virtual reality and computerised cognitive tasks are mentioned as options for restoring or maintaining memory and learning, but the evidence base is still developing.