After brain injury, how can a survivor learn to think, read, write, and function through the day if his memory is impaired? When brain injury impacts any form of memory, the person can have serious problems with learning, communication, socializing, safety, and regaining independence.

My husband Alan suffered a massive heart attack and cardiac arrest. Alan came back to life after an hour of cardiopulmonary resuscitation (CPR). However, prolonged lack of oxygen led to a severe anoxic brain injury. Alan lost his abilities to think, remember, read, write, walk, and talk. In my previous posts, I've described the impact of brain injury and the early stages of rehabilitation. In this post, I'll share some of the strategies we used to help Alan remember, learn, and function safely after he returned home from three months of in-patient brain injury rehabilitation.

Functions of Memory

Memory is one of the most complex functions within cognition. I'll be writing much more about cognitive rehabilitation in future posts, but for now let's focus on the essential memory functions we rely on every day. Information comes in through our senses, and enters the short-term or working memory so we can focus on a task or piece of information. If we need to retain the information, it is transmitted to a form of longer-term storage, called relational memory. Relational memory is made up of several parts I'll illustrate below.

Learning to Remember

When Alan came home we continued all the in-patient memory strategies and devised new ones. During the day we deliberately worked on several memory functions as he rebuilt skills, knowledge, awareness, and judgment.

I worried about Alan's safety as he walked around the neighborhood. So, I made a flier to distribute to our neighbors with a photo of Alan, our dog Molly, and me on it. In a brief paragraph, I explained that Alan had suffered a brain injury that made it hard for him to recognize people and follow directions. I asked that neighbors introduce themselves each time they met, and show him the way home if he seemed confused. Several people thanked me for explaining how to talk to Alan. When they greeted him with friendly handshakes Alan said, "It's like I never left the block!"

Many survivors benefit from electronic organizer systems. However, the simplest external memory aids worked best for Alan. The logbook where he wrote three things he did each day was his anchor. This helped with episodic memory—remembering events from his ongoing life. Over time, he elaborated on his entries and added photographs of visitors or scenery. We moved on to labeled sections with answers to his frequently asked questions (FAQ notes), newspaper clips that interested him, and instructions for exercise. The information sections boosted semantic memory—his memory for general facts. As the logbook became thicker, Alan said "I have a pretty exciting life for a guy who was in the hospital so long."

I bought jumbo packs of index cards to make labels, checklists, and schedules. Before going for a short walk, he checked the list hung on the front door for his keys, wallet, hat, and good-bye kiss for the wife. I tucked identification cards with names, my phone number, and his medical info in all his pockets. If he was doing an errand, a note saying "buy birthday card" helped with prospective memory—the ability to remember to do something in the future. My prospective memory also benefited from long lists to organize our complicated life.

He still struggled with naming and locating objects he used daily. I labeled the dish shelves with "plates, bowls..." On his bureau drawers, I decorated signs with drawings of sweaters, socks, pajamas. When he could find his clothes, the first step of dressing went smoothly.

Memory prompts were crucial to Alan's goals. His first goal was learning to feed our dog by himself. We wrote out the steps on an index card:
1. Go to kibble bin near stove. (He had to find it anew every morning.)
2. Scoop out ½ cup.
3. Put in Molly's dish.
4. Replace scoop and close bin.

At first I read the steps, and we worked up to Alan being able to refer to the card as he carried out the task. Repetition is key. It took three weeks of daily practice to learn, but feeding Molly became a source of enormous pride.

We learned to work with the type of memory that was strongest. Alan's procedural memory, from practicing motor functions, required only a few practice sessions to come back online. He learned to bike again, and enjoyed swimming. Alan's self-esteem skyrocketed when he could teach the youngest family members to swim. writing about riding his bike in his log book made it easier to recall the experience.

Alan had the idea of writing his autobiography to remember more, practice composing sentences, and practice writing on the computer. He had more access to early childhood memories than recent years. His first story was about Christmas with his Jewish family who ran a toy factory. They celebrated together to relax after their busiest season. It took Alan days to write each story. He interviewed family members about details he forgot. When he had six "chapters", we made books and sent them to his family.

Teaching back what you know is a great memory and learning strategy. So, I asked Alan to teach me how he walked our dog, or found his way to the park and back.

In my book, Professor Cromer Learns to Read, I detail Alan's memory deficits and strategies we relied on over several years..

Tips for Caregivers:

1. Believe what the survivor tells you. Getting angry or nagging him/her to remember only adds pressure and anxiety.

2. Put it in writing. Any important information should be written down right away. Make checklists for routine activities. Make lists to organize and prioritize time.

3. Try a log book or journal. The effort of writing a few sentences will be worth it. Before going to bed, write plans or goals for the next day.

4. Use all the senses to make memories.

5. Write instructions in a few, simple steps.

6. Use external memory devices to enhance independence. They can be as simple as index cards and alarms, or more complex such as smart phone apps.

7. Build on the type of memory that's still strong. If memories of long ago are present, practice writing stories. Look up historical events from that time and add to story. If procedural memory is strong, build confidence by playing a sport or video game.

8. Rehearse important events. Talk about what will happen, what might cause anxiety, and how he/she can feel in control. Write a few "talking points" to start conversations.

9. Be very patient. Take a deep breath instead of saying, "I've told you that ten times!"

References and Resources
1. Brain Injury Association of America (2007). The Essential Brain Injury Guide (4th ed). Ypsilanti, MI: Rainbow Rehabilitation Centers, Inc.
2. Lash and Associates Publishing/Training, Inc. Sells an extensive collection of books and training materials for professionals, survivors, and families.

About the Author

Janet M. Cromer R.N., L.M.H.C.

Janet Cromer, R.N., L.M.H.C., is a nurse, psychotherapist, and adviser on brain injury caregiving.

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