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Returning to Work With Cognitive Impairments

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Cognitive impairments can develop over time as a result of disease such as a brain tumor, or be the result of a sudden trauma such as a head injury. In some situations, individuals appear to make a full physical recovery but can be left with subtle, "invisible" cognitive impairments that affect their ability to process information, organize tasks, and maintain a reasonable attention span. Yet these impairments may have a major, negative impact on their ability to return to work, and manage household or family tasks and roles. Occupational therapy practitioners provide skilled interventions that help these individuals maximize independence and develop the skills to participate in activities that are meaningful in their daily lives.

Individuals who experience cognitive deficits are challenged by the daily routines that are necessary to function in today's society. They are expected to perform tasks and meet job expectations that they previously could handle, but they may no longer be able to do so in a timely manner or at all. These individuals are often overlooked by medical professionals or employers as needing services because they look as "normal" as they did prior to injury or onset of disease: However when demands or expectations increase, or their structured routine is altered, they may begin to struggle. Often times, these individuals will have subtle deficits that are not identified until they return to the demands of the workplace. Such individuals may be viewed as "difficult" and "difficult to manage," but in reality, their behavior is the result of relatively subtle cognitive deficits. Research shows that rehabilitation focusing on injury-related difficulties, socially appropriate behavior, appropriate career goals, and characteristics of the work environment (e.g., compensations, modifications of former job duties, etc.) can increase job placement and retention (Klonoff, Lamb, & Henderson, 2000).

The Effects of Cognitive Impairments on Performance
Cognitive impairments can affect people's ability to perform daily functional tasks, including but not limited to:

  • Difficulty perceiving their role in the work environment, such as not understanding relationships with supervisors and colleagues, being prone to social errors, and perceiving their new role as less valued.
  • Inability to formulate, plan, and execute a process without structure, initial support, or guidance.
  • Short-term memory impairments so they may not return phone calls if they did not write the information down or remember who they spoke to, they may forget to follow up on tasks, or they may not be able to apply information to similar tasks.
  • Auditory processing impairments leading to completing tasks incorrectly because they mis-hear spoken instructions.
  • Visual–spatial impairments leading to misunderstanding written instructions or needing guidance on attending to the entire work environment, especially if they have visual neglect or impairment.
  • Decreased insight, attention, problem solving, and sequencing so they miss vital information due to inability to focus on work, distractions in the environment, a general lack of understanding of what is needed to complete the task, and the inability to focus on more than one thing at a time.
  • Reduced self-care abilities, which may lead to increased time for self-care activities (such as bathroom breaks).
  • Poor sleep patterns because they are trying to do everything "right" but the lack of sleep may lead to increased fatigue, irritability, and errors.
  • Anxiety or depression over their work performance, so they may feel that they are being scrutinized, which will only increase their anxiety. They may also experience depression, realizing that their job performance is not what it was before their injury. Anxiety and depression can lead to financial strain and relationship challenges.
  • Decreased driving ability, which affects how and when they get to work.

The Role of Occupational Therapy
Below are some of the ways in which occupational therapy practitioners play a vital role in addressing the deficits often experienced by individuals with cognitive impairment.

  • Analyze the client's role in the workplace and provide recommendations to the employer and individual on ways to be successful. This intervention can begin in an outpatient setting to generalize and practice the tasks needed to successfully complete work responsibilities before actually returning to the workplace.
  • Create a memory book or set up external aids (e.g, a smart phone reminder) to help the person perform a specific task, assist with organizing the daily work flow, and offer cues for timelines and deadlines.
  • Train the individual with auditory processing impairments in compensatory strategies such as asking the supervisor to provide written information or e-mail requests versus just verbal instructions.
  • Assist with vision rehabilitation and train the client on ways to best maneuver in the environment with visual impairments.
  • Set up goals and work on cognitive rehabilitation to improve insight, attention span, carryover, problem solving, and sequencing while also decreasing external stimuli.
  • Address relaxation and stress management to help the individual achieve restorative sleep, to better function at work.
  • Address clients' mental health to help them function successfully. This is a vital step in ultimately resuming a productive life, as these individuals want and need to work to maintain self-esteem and the ability to support themselves and their families.
  • Evaluate the ability to resume driving, which can be an important factor in determining an individual's ability to return to work safely. Some facilities have driving programs that include specialized evaluation and on-the-road testing, but even generalist occupational therapists can assess performance skills that may have an impact on the future ability to drive safely or use alternate community mobility options. 

Conclusion
Anyone with a cognitive impairment who wants to return to work can benefit from occupational therapy services. These services can be provided initially at either an inpatient or outpatient clinical setting, then at the client's workplace to provide coaching and determine what supports may be necessary during a transitional period. There are also home care agencies that work with individuals who have specific conditions resulting in cognitive impairments.

Occupational therapy practitioners play a vital role in returning individuals to work through their unique ability to provide evaluation and intervention for an individual's performance deficits and workplace demands to maximize opportunities for successful reintegration of an important daily occupation.

Reference
Klonoff, P. S., Lamb, D. G., & Henderson, S. W. (2000). Milieu-based neurorehabilitation in patients with traumatic brain injury: Outcome at up to 11 years postdischarge. Archives of Physical Medicine and Rehabilitation, 81, 1535–1537.

Developed by Sheri Purdy, CLT, OTR/L, for the American Occupational Therapy Association. Copyright © 2012 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact copyright@aota.org.