Cognitive Dysfunction

Possible social consequences of executive dysfunction

Additionally, because executive dysfunction is a cognitive deficit, it is not easily visible to others and can be mistaken for laziness or incompetence. This may make the concussed person feel angry and embarrassed and affect their relationships with others. 

Executive function and Decision Making: The Science

Additionally, flexible thinking, or readily changing behavior based on new information, may be difficult. Instead, a concussed person may stick to using the same information, and employing the same behaviors and same strategies, even when situations change and new strategies would be helpful. They may also need help developing solutions to their problems or solving them in general. Concussed individuals may also have difficulties planning, thinking many steps ahead, and predicting the consequences of their actions, which often results in impulsiveness. 

A study by Ledwidge et al. compared 16 young adults with a concussion to a control group and found that the concussion group had lower language, memory, and executive function skills (but these were still in the normal range). In contrast, attention and visuospatial skills did not differ between the groups. However, using EEG while the study participants completed the cognitive tasks, researchers found an “enhanced negative N400 potential effect” in the frontal regions of the brain and less of a “negative N400 potential effect” in the “centroparietal” area. This potential appears when a person recognizes an “incongruence” at the end of sentences (“The kite flew in the sky” vs. “The kite flew in the cup”). An enhanced negative effect focused at the frontal regions instead of the centroparietal regions suggests that these concussed individuals may show a “compensatory” response. 

The Components of Attention Network 

Attention has three different components: alerting, orienting, and executing. 

• Alerting: The alerting component refers to the level of alertness and how alert the person can be. The reticular formation is the primary brain structure that is involved. 

• Orienting: The orienting component refers to the person directing themselves to and keeping their attention on a particular stimulus. The posterior parietal cortex and thalamus are brain structures involved. 

• Executing: The execution component uses the necessary attentional processes, like sustaining, selecting, and dividing attention. The prefrontal dorsolateral cortex and orbitofrontal cortex (see the image above in the executive function section) are the brain structures involved in this process. 

One study found that individuals with a concussion have deficits in their orienting attentional network but not the alerting or executing attentional networks. This study team used several different tests to measure the various attentional networks in concussed individuals.

• The Attentional Network Task (ATN) assessed these three networks together. 

• Additional tests for the attentional network: the Digit Span task, Trail Making Task A, and Stroop Color task. The concussed individuals performed worse on these three tests when compared to controls, indicating they had greater impairments in overall attention abilities. 

However, another study found that the executing component of attention is also affected by a concussion in addition to the orienting component, suggesting that some concussed people may take longer to actually “initiate a correct response” to the stimuli. Overall, it is evident that the brain’s attentional capabilities are affected by a concussion. 

You may be experiencing memory issues if you: 

• Do not keep scheduled appointments, arrive at the right time, or follow through on plans.

• Have difficulty finding items around the house, like keys and cell phones.

• Lose track of money or forget where you spent it. 

• Repeat questions multiple times.

• Forget to take medication on time or with the correct dosage

• Need help remembering instructions or directions.

• Forget procedures you are usually familiar with, such as making coffee. 

• Forget peoples' names or occasions such as birthdays, holidays, and family events.

• Feel unsure of what you did or said in the past hour, day, or week.

• Lose track of time or feel uncertain of what day it is.

• Forget what has been said in a conversation.

• Are unable to retrace a route you took earlier in the week.

• Forget what you saw in a movie or read in a book or magazine.

You may be experiencing processing speed issues if you:

• Find television shows and movies hard to follow even if the volume is high and the image is clear

• Find it hard to understand friends when talking in noisy places such as restaurants or bars. 

• Often feel like you are missing something in conversations. 

• Have trouble understanding foreign accents.

• Take longer to read and understand books, newspapers, or magazines.

• Take longer to carry out tasks, including routine tasks such as getting dressed or washing your face. 

• Take longer to wrap your head around what someone is saying. 

• Take a long time or have a hard time following directions. 

• React slowly to changes in your surroundings. For example, you do not react quickly enough to stop signs, traffic lights, and other warning signs while driving. 

Additionally, researchers have found that poor cognitive function in language comprehension and attention is associated with an increased likelihood of migraines. Migraines are also associated with slower processing speed. Depression and anxiety did not affect the relationship between migraines and cognitive dysfunction. 

It is clear that there is an association between cognitive dysfunction and mental health, so it is crucial to consider both when constructing a treatment plan. 

• Identify the reasons why a task or activity is important. It can help us to complete something if we know why we are motivated to do it. 

• If something must be done, write it on a sticky note or a piece of paper and put it in a noticeable place. When you are done, cross the item off, toss the note, or otherwise physically mark that you completed the task. 

• Not only does this help you stay organized, but it also can give an extra sense of accomplishment that you did something productive.

• Set phone or watch alarms for when you want to start and finish activities. 

• Re-read text, highlight important information, take notes, and try to summarize what you have read in your own words.

• Ask others to repeat themselves, speak slower, or rephrase something. 

• If someone is trying to tell you too much information at once, ask them to say one thing at a time. 

• If someone asks you multiple questions at a time and you can’t keep up, you can also request that questions be asked one at a time

• Take plenty of breaks if you get tired. 

• Decrease distractions, such as background noises from television, speakers, other people, unnecessary phone reminders, or distracting lighting. 

• Focus on only one activity at a time.

• Practice attention skills on simple activities first, like reading a short paragraph or doing simple math.

•  Over time, increase the difficulties of the tasks, such as reading full articles or short stories. 

• Gradually introduce common distractions, such as moving to a more noisy environment

• Mood can make it more difficult to concentrate, so speak to your doctor if you think depression or anxiety could be worsening your ability to concentrate. 

• Anxiety can significantly affect attention. For more, see our page on Mental Health.

• Break down big tasks into smaller steps. This will help them be more manageable and decrease feelings of anxiousness while working on a project, which may improve your concentration.

• Get plenty of rest. Attention is one of the first things to go when you lack sleep. Talk to your doctor about any problems you have sleeping.

• Speak slowly and do not include too much information between pauses or chances for their input. 

• Work with your loved one to find the right pace to speak at and help them practice asking you to slow down or speed up as needed. 

• Work on a signal, such as a simple hand signal, to let the injured person know when they are starting to get off topic in a conversation. Practice this ahead of conversations. If you would rather not use a signal, you can say, "We were talking about…." 

• Have one-on-one conversations before trying to talk in large groups. 

• Practice clear communication of your feelings and needs with your loved one. 

• Help them practice the tips from the previous section. Practice in a place with few distractions. 

• Join your loved one sessions at your sessions with a specialized healthcare provider who works with cognition dysfunction. If you are there to listen to the healthcare provider's advice, you can help implement it at home. 

• Give the person extra time to think before offering your own solutions or providing more information.

• Offer to solve problems with them, not for them. This can take the form of guiding questions such as "what is the first step?" or "how would you begin?". 

• This can help individuals gain independence and self-confidence. 

• Limit distracting sounds, activities, or people when conversing. These can be background noises, multiple speakers, poor acoustics, or complicated visual patterns on clothing or furniture.

• Offer honest praise for improvement.

• Don't expect them to be able to do multiple tasks at once. 

• Practice direct eye contact or appropriate friendly touch, which can help with attention.

If your loved one has memory issues, you can also: 

• Repeat instructions or directions without talking down. 

• Ask your loved one to paraphrase what you just told them and offer assistance with details. Focus on what they got right, and kindly repeat what they misremembered.

• Put important notes and information in writing. It is much safer to rely on written information than auditory information. If they write down what you say, look over what they wrote to ensure it is accurate.

• Consistently review plans and incorporate repetition throughout the day. 

• Suggest memory aids. 

Additionally, in a recent study, omega-3 fatty acids have been connected to improved brain structure and cognitive function in middle-aged adults. Omega-3 fatty acids are found in flaxseed, fish, and fish oil dietary supplements. The body cannot produce the primary Omega-3 fatty acids, so diet is crucial for maintaining appropriate levels. 

However, please consult a medical professional to determine if exercise is right for you. A physical therapist or physician should guide exercise post-injury. Be cautious about your safety and monitor your symptoms as you exercise. If your symptoms worsen, stop the exercise immediately. For more, see our resource page on Graduated Exercise Therapy, our Overview of Self Care section on exercise, or our blog post Aerobic Exercise as Therapy.

Apps and Activities: Several apps can be used in remediation treatment, such as Lumosity, BrainHQ, Brain Fitness, and Constant Therapy, which speech-language pathologist Kam Gardner sometimes prescribes. She recommends using these three times a day (using them before or after meals will help you remember to use the app consistently) for 20-30 minutes at a time. If you are starting to fatigue, take a break and try again later.