Cognitive Interventions for Traumatic Brain Injury

When you’re new to working with patients affected by acquired or traumatic brain injuries, it can be challenging, exciting, and even stressful as an OT student or new occupational therapy practitioner. This is especially true if you have not been exposed to many of these types of patient or any cognitive interventions for traumatic brain injury.

The purpose of this article is to cover basic must-know information and helpful cognitive intervention ideas so that you can be prepared and equipped to provide the best care for your patient.

Please note that these interventions will also work for patients affected by an acute stroke or any other new injury or illness affecting their cognition. As with any intervention, you’ll always want to make sure the treatment you’re providing is client-centered and graded appropriately for each individual. 

First, What is a Traumatic Brain Injury (TBI)?

AOTA’s definition really sums it up pretty clearly and concisely, defining traumatic brain injury as…

“…an occurrence that happens when the person’s head is severely hit or shaken, or when an object goes into the brain, and can range from mild to severe.” AOTA’s TBI Fact Sheet, 2016.

The most common causes of TBI are car and motorcycle accidents, falls, and other accidents that result in trauma to the head.

AOTA explains that,

“…individuals with TBI may have changes to their personality, trouble with memory, confusion, or poor judgment. They may be tired, depressed, or anxious. The changes to the brain after TBI can affect people’s ability to do daily activities (occupations). It may also affect their roles, such as employee, spouse, parent, and friend.”

This is where we as occupational therapists come in to help our patients with traumatic or acquired brain injuries live their most productive lives as independently and safely as possible.

You May Be Working with Patients with Agitation at Times

As a therapist, you always want to be aware that your patient could be agitated and combative, depending on their Ranchos Los Amigos level. It also may depend on how much stimuli they are receiving, which can be a lot in the hospital – especially with staff that may not be as educated in this area.

If your is patient agitated, first look at the surrounding environment. Is the TV on loudly? Are all of the fluorescent lights on brightly? Are several family members talking to the patient or each other at once? Do you notice nurses speaking loudly at/in front of the patient?

Whether your patient is or is not agitated, they all will benefit from low stimulation environments while their brain is healing. Be sure to keep this in mind before you bring your patient to a crowded, loud gym. This can be just as detrimental as the above reasons.

Team Up With Speech Therapy

Another tremendous benefit will be to collaborate with your patient’s speech therapist to make sure you two are on the same page with cognitive interventions. It’s also very important to make sure you aren’t doing the same things!

Occupational therapy can get muddy with speech therapy since they are also working on attention, memory, problem-solving, etc.

6 Functional Cognitive Intervention Ideas

These treatment ideas tie into ADLs/I-ADLs (these may differ from what works in your setting):

1. Meal Prep

Hopefully you have a training kitchen in your setting because you can work on so much cognitively with this activity. Following a recipe, listing ingredients, following prep instructions, planning a meal and safety in the kitchen are great ways to not only work cognition but help prepare your patient for going home.

2. Medication Management

If your hospital has a pre-made medication management kit, then you’re all set to help your patient practice setting up daily medications using the pill box organizer and fake medications.

If not, here is a link to make your own medication management kit.

3. Money Management

You can use “play” money that your rehab facility may have already. If they do not, you can get an inexpensive play money kit with coins and bills on Amazon and use it again and again with future patients with cognitive deficits to work on paying for purchases, ordering from a catalog, simple adding and subtracting, and budgeting.

You can create these yourself by using a day planner, calendar, or creating a memory book to assist the patient in writing down what they have done that day. You can add pictures of family members with their names written down, important phone numbers, addresses and dates.

4. Leisure Activities

This might include things like puzzles, card games and word finding sheets which all work on attention, concentration and focus, which can be affected after brain injury or stroke.

For more detail on specific games to play based on your patient’s cognitive and physical deficits, check out this helpful article, 10 Best Brain Games from Senior Lifestyle. It is targeted towards older adults but the games are going to work well for individuals with TBI as well. 

5. Orientation Activities

Working on basic orientation with your patient is so important if they’re having difficulty knowing the date/time, where they are and/or why they are in the hospital or rehab facility. So often other providers come in and out quickly to assess without explaining to their patient what is going on with them, so basic orientation is always important to address if you notice any difficulty with this.

If you are able to safely get your patient up and moving, navigation and route planning around the unit and hospital are other great ways to work their cognition and help them get a feel for where they are when newly hospitalized. It’s also so refreshing for them to get out of the hospital room and see new things, but only do this activity if you feel your patient has adequate safety awareness for this.

6. ADLs!

Basic ADLs, more often than I-ADLs at first. If you have a patient that is at a Ranchos stage that they cannot cognitively work on I-ADLs yet and is showing difficulty with motor planning, sequencing, initiation, or attention, I like to do repetitive basic ADL retraining.

This includes mainly the basics such as dressing, bathing, toileting and self-feeding, if they are not on swallow precautions/NPO.

You’ll want to really focus on the environment to make sure it’s not too cluttered or distracting. Turn off the TV and focus on one task at a time as well as your cuing.

You want to ensure you are providing simple cues like “What is this?” or “Brush your hair” and “This is a shirt” if your patient is at this level. Remember the KISS acronym of Keep It Simple, Sweetie!

Remember to Educate Others

Don’t forget to educate their caregivers on these cuing tactics as well, since family can sometimes be overstimulating without realizing it.

Caregivers (including hospital staff) will also benefit from education on the injury and the nature of your patient’s cognitive impairment.

You should also make post-discharge recommendations like 24 hour supervision (if needed) when your patient goes home. Don’t forget to add ongoing education about safety recommendations like grab bars, swallow precautions, impulsivity, etc. This will help your patient reduce the risk of any further accident or injury.

Always Tailor Your Treatment Plans

I also want to point out that these cognitive interventions are not one-size-fits-all, and each patient will be different and respond differently.

As mentioned in the intro, be sure to grade these up or down and make sure each treatment fits into the “just-right challenge.” Treatments that are too difficult or too easy can lead to the patient becoming frustrated.

Your patient may also demonstrate physical limitations, so remember to keep that in mind and incorporate interventions targeting those limitations as well. You want to help the patient both physically and cognitively.

Other Important Things to Know

• If a patient is showing signs of agitation or frustration, try not to stand right in front of them; give them space and try to remind yourself not to overstimulate them as you’re providing the intervention.
• Cognitive rest breaks are very important. Think of it as taking physical breathers during the interventions, as your patient is working really hard cognitively to perform the task you’ve given them. It’s always okay to take breathers!

What Happens After Rehab?

If you are working in acute or subacute rehab with patients with brain injury, you will learn quickly that the patient’s brain might not be “healed” to it’s full potential. Inpatient stays are usually one to three weeks and the brain can continue healing for 12 months or more. This of course varies for each person.

If you are in an inpatient setting, you can recommend home health OT followed by outpatient neuro rehab or community-based rehab for your patient to continue to work to regain the skills needed to thrive post-hospital discharge.

For a great resource all about community reintegration, check out this easy to follow Community Reintegration Fact Sheet from AOTA. I highly, highly recommend reading this sheet so you can fully understand the continuum of care post-discharge

For even more helpful information on traumatic brain injuries, be sure to also check out AOTA’s TBI Fact Page here. 

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I hope this post helped you form some ideas of what you can incorporate as cognitive interventions for your rehab patients.

If you’re looking for a deeper dive, be sure to check out all of the great CEUs covering brain injury and stroke rehab on MedBridge Online Continuing Education as well.

What cognitive interventions would you add to this article? Please share your favorites, along with any tips in the comments below.

This post was originally published on May 8, 2016 and updated on March 22, 2020 and May 25, 2023.