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-Attention is the allocation of processing resources

-Attention forms the foundation for which all other cognitive skills are based

-Attention difficulties may be more pronounced in less structured environments

-Attention is the foundation for all cognitive processes are built upon.


Types of Attention

1. Focused/Sustained
2. Selective
3. Alternating
4. Divided


Focused/Sustained Attention

The state of focusing on one stimulus to the exclusion of all other competing stimuli

-“I try to watch TV but I just drift off.”


Selective Attention

-The ability to focus on the important/relevant stimuli in the presence of distracting stimuli

-“I can’t cook while there is noisy construction work happening next door; I get too distracted.”


Alternating Attention

- An individual is asked to focus on any two tasks that require thought and are completed at the same time

-“I can’t listen to a lecture and take notes at the same time.”


DIvided Attention

-An individual is asked to complete two tasks at once but one of the tasks requires little to no thought

-“I can’t brush my daughter’s hair while talking on the telephone; can’t do two things at once anymore.”


Frontal Lobe Disorders

The frontal lobes are responsible for higher-order functions; executive functions, emotional-behavioral-social control regulation, motor functioning, and the appropriate use of language, social pragmatics, and the subtleties of communication (innuendoes, humor)

- Think of EMAPS

- Houses intellect, cognitive processes, and regulates emotions


Frontal Lobe Damage

Motor impairment; halting/disorganized speech; personality changes; aphasia; apraxia; difficulty with emotional/behavioral control; Patients may exhibit passivity, apathy, or lack of internal drive/motivation


Executive Functions

-The executive functions relate to one’s ability to use cognitive skills efficiently in a complex environment

-EFs help us regulate our abilities so we can achieve goals

-EFs are often performed without thinking and may be age-related in terms of development

-EFs are an umbrella term that encompass many different skills


List of Executive Functions

1. Planning and organization
2. Multi-Tasking
3. Learning Rules
4. Motivation
5. Generalization
6. Flexible Thinking
7. Problem Solving
8. Social Behavior
9. Initiating/Inhibiting Behavior
10. Controlling emotions
11. Monitoring Performance
12. Self- Awareness
13. Making decisions
14. Goal setting
15. Insight
- do not need to think about performing these tasks (very little thought involved)
EF's allow you to have morals- determine right from wrong


Commonalities: Executive Function

-Patients may begin a task prior to thinking through all of the steps

-Repetition of a thought, behavior, action, or verbal utterance that continues even though it is no longer appropriate

-Patients tend to think about features in lieu of groups or categories

-Inability to focus on more than one thing at a time
Patients are easily distracted


Pre-morbid responses

- Prior to injury

- inhibition

-emotional stability



- Cognitive-Communication Deficits

- Disinhibition

- Emotional instability



1. Person

2. Place

3. Time

4. Purpose

- A patient is orientated times 4

- Could be person, place, month, and year.

- Use a calendar to reorient the patient about time


Types of Memory

1. Procedural (implicit)
2. Declarative (Explicit)
3. Long term
4. Recall
5. Short term
6. Episodic
7. Prospective


Procedural (implicit)

Ability to perform skills in the absence of conscious awareness (motor memory). Remember the procedure for riding a bike.


Declarative (explicit)

-Factual memory, ability to do algebra, do well on tests, ability to recall so you don’t forget. Declarative memories can become procedural memories.


Long-term memory

- (LTM)- recall of previously known information (remote memory) The ability to remember information we have stored. Challenge yourself-crossword puzzles and brain teasers


Short-term memory

- (STM)- immediate recall of new visual or verbal information. Can recall 7 items, plus or minus 2
- can use chunking to remember (don't do this or add intonation to the list that a patient needs to remember)


Recent memory

Delayed recall of information up to 30 minutes


Prospective memory

The ability to recall information needed in the future


Episodic memory

-Recall of temporarily dated events. Tied to a date in time or an episode


Problem Solving

1. Identifying Problems

2. Generating Solutions

3. Organizing

4. Sequencing

5. Implementing Solutions

6. Managing Time

7. Self-Monitoring

8. Safety

o Needs to use attention skills as well as executive functioning

o Organize- make lists

o Sequencing- steps in order of importance


Broad based test

- nonspecific tests, test all aspects of language or cognition- CASL or CELF


Specific tests

o Specific tests- EOWPVT (semantic test) and ROWPVT (receptive semantic test)
• Behavioral test of inattention- targets attention


Critical thinking

1. Drawing inferences
2. Deductive reasoning
3. Inductive reasoning
4. Abstract reasoning
5. Flexibility of thought


Drawing inferences

- Making a connection between two otherwise unrelated facts


Deductive reasoning

- Arrive at a conclusion based on known facts


Inductive reasoning

- The process of determining how to achieve a goal or solve a problem (involves inference)


Abstract reasoning

- Drawing conclusions based on notions, ideas, concepts that are not tangible


Flexibility of thought

-Shifting from one idea to another with relative ease



-Aspects of behavior associated with cognitive communication disorders
- metacognition
- communication problems


Communication Challenges

-Cognitive-Communication challenges impact the social, academic, behavioral, and vocational lives of survivors

-Typically, survivors of TBI have intact grammar and semantic knowledge; language appears fluent

-Deficits tend to lie in the areas of meta-semantics and pragmatics (both verbal and nonverbal types)


Meta-Semantic Deficits

1. Word-retrieval deficits (anomia)
------Shed light on deficits- create deficit awareness for patients
------Give patients time to process information
-----Patients can have poor deficit awareness
-----Latency period- period of time when you ask patient to respond and their response. In assessment you can note that a patient has an increased latency period.

2. Lack of cohesive speech with poor knowledge of figurative language; their language can be very concrete centered

3. Difficulty understanding words with multiple meanings

4. Difficulty integrating and synthesizing information (parts = whole); figuring out salient from irrelevant information

5. Slower processing speed

6. Confabulation (lack of truthfulness)



-Pragmatics is generically defined as the social use of language

-Pragmatics is specifically defined as functional use of verbal and nonverbal modes of communication to convey and interpret intended messages


Verbal pragmatic deficits

-Tangential Speech: Conversation topics shift without listener notification

-Limited communication initiation or maintenance per interaction with others

-Decreased topic maintenance

-Inappropriate topic selection

-Inadequate topic relevance

-Poor presupposition skills
---implicit assumption about the world or background belief relating to an utterance whose truth is taken for granted in discourse.

Jane no longer writes fiction.
Presupposition: Jane once wrote fiction.


Nonverbal pragmatic deficits

-Poor eye contact; includes both too much and insufficient amounts

-Flat affect; Poor use of facial expressions to convey emotions

-Lability; emotional excess

-Inappropriate proxemics

-Inappropriate physical contact

-Decreased understanding of other’s nonverbal cues



-Traumatic brain injury can leave old memories intact but hinder the ability to store and/or retrieve new memories; also includes learning new information

-Impaired attention can also make learning new information difficult


2 types of Amnesia

1. Anterograde amnesia

2. Retrograde amnesia


Anterograde Amnesia

-Loss of the ability to learn and recall new information after the trauma


Retrograde Amnesia

-Loss of memories stored before an injury



-Change in behavioral state as a result of abnormal electrical activity within the brain

-The occurrence of a seizure in the presence of some acute precipitating physiological disturbance does not mean that it will ever happen after the cause has been resolved

-When seizures occur without any obvious precipitant or cause, then a person may be considered to have a form of epilepsy

o Know the different types of seizures in case you see them in a chart
o No medicine can prevent TBI seizures
o Place patient on the floor, move everything out of the way


Seizure Types

1. Generalized Seizures:
Increased electrical impulses occur throughout the brain

2. Partial Seizures:
References relatively small electrical impulses in more focal parts of the brain

3. Nonepileptic Seizures:
Not caused by abnormal electrical activity in the brain

4. Status Epilepticus:
Prolonged seizures; continuous state of seizure


Post-traumatic seizure disorder

-Seizures are common following TBI and are broken down into two separate categories:

- Seizures that occur within a seven day post-injury window; Patient is still in ICU or in the acute stage

-Late onset seizures that occur more as focal issues


General seizure information

-Seizure incidence is higher in children than in adults

-Late seizures are more likely to occur in adults or when the head injury was of the penetrating type

-There are no anti-epileptic medications that will protect against post traumatic epilepsy

-Depressed skull fractures and hemorrhagic contusions tend to predispose patients to seizure disorders


Concomitant Issues (TBI)

1. Post-traumatic headaches
2. Post-traumatic fatigue
3. Somnolence (sleepy)
4. Balance disorders
5. Sexual disorders
6. Depression
7. Mania
8. Anxiety Disorders
10. Personality Changes
11. Aggression


Depression following TBI

-The level of brain injury severity poorly predicts a patient’s level of depression or susceptibility to a depressed state

-Pre-injury depression is common

-Increased anxiety levels + depression often coinside

-Decreased left prefrontal gray matter volume often correlates with depression

-Pre-injury aggression and hostile features may predict suicidal behavior