The first part of cognitive retraining — restoring skills — is sometimes compared to rebuilding a weakened muscle. Exercises used in retraining programs may actually rebuild cognitive skills such as attention, concentration, memory, organization, perception, judgment, and/or problem solving. These exercises can include computer programs designed to improve visual-perceptual skills (our ability to correctly interpret what we see), reaction time, memory, and attention. A large chalk board or a practice grocery store shelf can be used to practice visual scanning and visual attention skills. Workbooks and puzzle books can help with reasoning, mathematical skills, memory, and visual-perceptual skills. These items can be found at teachers' stores or large discount stores such as K-Mart or Wal-Mart. It is important that the materials selected are neither too difficult or too easy.

Strategic games, such as "Uno" are also an excellent way to work on a variety of cognitive skills while interacting with others.

The therapy setting itself offers many opportunities to practice cognitive skills. Therapists can develop personalized tasks that require "thinking on your feet" and more closely simulate your real life situations. For example, for those who prepare meals, therapy may include using the program facility's kitchen to practice following a simple recipe or to plan, in sequence, a more complex meal.

For those whose jobs require organizational skills, the therapist may suggest using a checklist format to complete complex tasks or using the copy machine to practice planning skills and problem solving skills. One of our favorite activities involves patients organizing and ordering-out lunch from a local restaurant. This works on the skills required to make and follow a plan of action, the ability to keep track of details, and staying focused on a cognitive task. Another good way to work on memory is to ask the patient to relay a message, later in the day, to another therapist.

These are just a small sample of the activities and exercises available to rebuild cognitive skills. Working with a therapist allows selected tasks to be supervised and tailored to each patient's needs, strengths, and functional levels.

The second component of cognitive retraining is learning to use strategies, compensatory techniques, or "tools" to cope with weaker areas. Strategies are designed for each patient using his/her areas of strength to compensate for weaker skill areas. Learning to use these tools not only compensates for impaired ability, but may help to rebuild the skill itself. For example, using a checklist may actually improve attention skills. The following strategies are some of the other tools we find helpful for our patients.

MEMORY STRATEGIES
Take written notes and make certain that notes contain accurate, complete information. Including "who, what, where, when, and why" helps to ensure that notes have all the critical data. Refer to your notes regularly. Use association, visualization, repetition, rehearsal, and categorization to help with recall. Use a daily planner system to keep track of all information. It is too complicated to try and locate information that is recorded in several different places. Use a daily or weekly pill box to keep track of medication. Arrange items in an organized fashion and place them in strategic, easy-to-see locations. Consider using a tape recorder to record lengthy and/or important conversations.

ATTENTION STRATEGIES
Organizing your environment will help you maintain control. Use a self-talking technique to stay on track. For example, ask yourself "Am I wandering?" or "What should I be doing right now?" To improve your attention while listening to someone, make constant eye contact with the speaker, ask the speaker to slow down, request clarification or repetition, take notes, and/or ask the speaker to provide the information in an alternate way-such as in writing or with pictures. Make a checklist for lengthy tasks and check off each item as it is completed. Be sure to double check all work. Avoid fatigue: when activities start to become overwhelming or frustrating, stop and take a mental break. Reduce distractions as much as possible — turn off the radio or television, or close the door.

PROBLEM SOLVING STRATEGIES
List several solutions to a given situation, then list the pros and cons before deciding upon the best option. Ask yourself, "What else could I do?" and consider asking for someone else's opinion. Review the steps needed to solve the problem. Evaluate the success of the outcome.

ORGANIZATION STRATEGIES
Make a checklist. If a task is large or complex break it down into smaller parts and make a checklist for each part. Make a verbal or written "pre-plan." Prepare the work area with necessary materials. Eliminate clutter. Spend time making a daily plan using your planner system. Most people like to plan their day early in the morning when things tend to be quiet. Remember to prioritize tasks and pace yourself. Plan to work on more demanding tasks when your energy level is highest. Make and use "to-do" lists.

STRATEGIES FOR IMPULSIVENESS
Give yourself permission to take the time to think through tasks. Complete one task before beginning another, and use your checklist. Pause and think before acting (count to 5 or 10). If you become confused by a task, take a timeout before you become frustrated.

An important part of therapy is training and education of caregivers. It is important that those who spend the most time with the patient understand these cognitive strategies and encourage their use. Consistent practice of learned strategies is critical to becoming proficient in their use. Patience is the key word. It takes time for the brain to heal, and it takes time to learn new ways to do familiar things. The results are worth the effort!

If you are interested in learning more, we encourage you to speak with your doctor. He or she can make a referral to a rehabilitation facility offering these programs, or refer you to an individual practitioner in your area.