Neurofatigue

Definition

Fatigue that is organically based and NOT due to excessive activity or abnormal sleep patterns. It can emerge suddenly without warning, especially after engaging in a cognitively demanding task.

Signs and Symptoms of Problems

Lack of Energy to Engage: Difficulty engaging in activities of daily living, communicating with others, or social activities.

Low Arousal:   Difficulty waking up and staying awake throughout the day.   It may require auditory and tactile cueing to wake from sleep.   It may be hard to open the eyes.  

Decreased Alertness:   Decreased ability to maintain mental awareness of surroundings, leading to decreased response to them.

Strategies for Survivors and Significant Others

• Need to build awareness of the causes & effects of neurofatigue
• Help to identify early signs of fatigue (yawning, slow motion, in a "fog", etc.).
• Trust others when they offer feedback about your apparent fatigue levels.
• Encourage conservation of energy and establish set times for rest throughout the day.   Assure the person that taking "time out" is needed and is okay.
• Establish a routine for bedtime/wake times.
• Help to break large tasks into manageable chunks-use a checklist.
• Do not schedule too much in one day.   Spread activities out throughout the week.
• Have patience and "do what you can and don't worry about the rest"
• Minimize stimulation in the environment when a survivor is completing tasks.   Manage the "flood" of input (i.e. limit the number of people interacting with the individual).
• Consult physician to inquire about side effects of medications.   Could possibly induce drowsiness and be prescribed for later in the day.
• Adjust diet and exercise to facilitate a healthy lifestyle and to promote healing.   Increase water intake.

Adynamia

Definition

Low mental energy or apparent lack of will.   Not "dynamic."

Signs and Symptoms of Problems

Trouble Initiating:   Hard to get started on things.  

Difficulty Generating Thoughts/Ideas:   Run out of ideas quickly.   Do not give a lot of details in communication.

Lack of Spontaneity:    Loss of "spirit."   Others think you are not interested or are just "going through the motions."   Face often does not show emotion.   "Poker Faced"

Strategies for Survivors and Significant Others

• Do not tell the person that they are "lazy"-understand they most likely know what needs to be done, but they have difficulty getting started.   Offer support to get started.
• Establish "accountability contracts" with supportive others to help initiate activities
• Become aware of facial expression, posture, eye contact
• Over exaggerate emotions

• Provide written checklists to encourage participation

• Cue as needed to begin tasks, verbally or with timers/alarms
• Use a routine to encourage increased task anticipation

Strategies for Survivors and Significant Others

• Help to break large tasks into manageable chunks
• Schedule tasks and encourage sticking to the scheduled due date
• Speak louder (reduces monotone)
• Prepare by using notes to help initiate conversation
• Use to-do lists, timers, watches, beepers, and other adaptive devices to improve ability to self-initiate tasks

Disinhibition

Definition

A syndrome marked by difficulty properly directing and controlling energy and emotions.

Signs and Symptoms of Problems

Impulsivity:   Doing or saying things without considering the consequences.   Making decisions before thinking about all of the information.

Feelings or behaviors come on too strong and/or too fast:   Feelings come to the surface and are hard to hold back.   Reacting to small things with too much emotion.   Talking too loud or too fast when the topic is emotional.  

Restlessness:   Hard to keep still.   Intense and frequent need to move or fidget.

Irritable and Easily Frustrated:   Hard to forget even small irritations.   Brooding.   Often require others to help calm down.

Emotional Flooding:   Can become easily overwhelmed when feeling challenged socially or cognitively.   Mind "goes blank."   Once flooded, it is temporarily impossible to think clearly or act purposefully.

Strategies for Survivors and Significant Others

• Visually/verbally cue the person to slow down.  
• Build in delays.   Establish automatic "pauses" between each task.   Use a stopwatch if needed.
• Ask the individual if they would do better if they put more thought in to a decision.  
• Consult a coach or family member before acting and gather further feedback
• Use this sequence "Stop, Think, Act, and Evaluate" and analyze how they did afterward
• Use self-talk strategies (i.e. Could I go slower? Did I think about this long enough? ).
• Be direct in response to inappropriate behaviors (i.e. interruptions, inappropriate remarks, tone of voice, awkward facial expressions)
• Teach relaxation strategies
• In a tactful way, let the person know how they are coming across (i.e. "when you say I do this, it makes me feel.").
• Ask permission to videotape an interaction with the person and later analyze with the person
• Verify what was really seen, heard, or felt to know if feelings are justified
• Encourage use of breaks to relax, calm down, and re-attempt communication when ready
• Seek coaching
• Ask the other person to slow down if they are making you irritated.
• Excuse self from current situation if too upset
• "SAVE" strategy (Stop, Ask, Verify, Evaluate)

Attention/Concentration

Definition

Staying awake, alert and ready, focusing, and keeping a train of thought.

Signs and Symptoms of Problems

Hard to Stay Alert:   Not enough mental energy to engage fully in the environment.

Hard to Focus Attention:   Easily distracted by noises and things around you.   Distracted by personal thoughts, feelings, and worries.

Lose "Train of Thought:" Once able to focus, a person may lose "train of thought" or concentration if distracted.   It may be hard for a person to make a point without getting off track and "rambling."

Strategies for Survivors and Significant Others

• Allow extra time for task completion
• Limit distractions during task completion
• Provide cues as needed to sustain task focus.   Set timers/use alarms to remind to re-focus.  
• Verify performance for accuracy
• Direct person back to the current topic when conversation becomes unfocused
• Encourage eye contact and participation during conversation (asking questions, nodding/shaking head)
• Reduce environmental distractions (i.e. closing doors, reducing glares)
• Teach strategies such as using a line guide to reduce amount of information to attend to on a page
• Improve visual attention by scanning left to right and top to bottom while using finger to anchor eyes
• Repeated verbal/visual cues to "slow down and pay attention to details"

Information Processing

Definition

Taking environmental stimulation in through the five senses, interpreting it, and responding to it.

Signs and Symptoms of Problems

Thinking Speed and Response Times are Slower:   It takes longer to understand sensory information and make sense of what is going on in a situation. There may be a long pause before the person responds with words or behavior.

Process only Fragments of Information:   Because of the slowed processing speed, parts of information heard or seen may be missed.

Social Inappropriateness:   Difficulty interpreting and making sense of social cues and body language of others.

Strategies for Survivors and Significant Others

• Encourage organization of information given
• Verify written, read, and verbal information gathered.
• Encourage single task completion; rather than focusing on multiple tasks
• Concentrate on accuracy first and speed later
• Write information down to give to the individual as a means to allow extra time for better comprehension/understanding.
• Ask others to slow down or repeat information
• Reduce visual distraction, auditory distraction, and internal distractions
• Practice, Practice, Practice to improve efficiency of specific skill areas
• Improve word retrieval and thought organization through practice conversations
• Impose time restraints to improve concise speech

Memory

Definition

Taking in new information, holding on to information, and recalling information when needed.

Signs and Symptoms of Problems

Difficulty Retaining New Information:   Hard to hold on to even brief instructions or explanations.   Difficulty remembering what was said at the beginning of a conversation.

Difficulty Storing New Information:   Information is not retained long enough to be permanently stored.

Difficulty Retrieving Stored Information: Hard to recall the main point of a conversation, even if it just occurred.   May forget important things learned from experience, causing mistakes to be repeated.  

Strategies for Survivors and Significant Others

• Use external strategies (i.e. calendars, lists, planner, timers)
• Increase awareness of problems to increase use of strategies.
• Follow a daily structure/routine
• Allow repetition of new information or tasks to assist learning and recall
• Provide information in small pieces rather than lengthy ones
• Provide visual as well as verbal instruction of new tasks
• Help to develop associations/mnemonic devices to improve carry over of information learned   (associate old information with new)
• Determine strengths and weaknesses with memory, and use strengths as much as possible (i.e. verbal memory vs. visual memory vs. learning by doing).
• Write important information down in a consistent location and organized fashion
• Place items in a common location (i.e. keys in a bowl by front door, bills in tray)
• May need to rely on trusted others for memory
• Journal the day's events as they occur