Understanding Cognitive Challenges in Stroke Recovery

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I’ve often joked with people that I feel like a one-speed bicycle after stroke.

If you ask me to do one thing, I can do that one thing just as well as I could before I had a stroke.

Now, I certainly can’t do it as quickly as I used to, but I can finish any task from start to finish and be satisfied with the final product.

However, if you ask me to do something and then interrupt me to change plans or ask me about something different, then oh boy, we’re going to have a problem.

That often feels impossible — you’ll make my head want to explode as I try to think through all my options on how to respond.

Initially, I had no idea why changing tasks and making decisions after stroke felt so brutally difficult.

But over the years, I’ve learned that my experience isn’t unique. Cognitive challenges, such as executive dysfunction – difficulties with planning and shifting tasks – are pretty common after a stroke.

According to the American Heart Association, more than 50% of stroke survivors develop some level of cognitive impairment within a year after stroke.

It’s an example of how recovery after stroke involves so much more than the physical challenges that are prioritized in therapy and what people see every day.

What is Cognitive Impairment After Stroke?

Cognitive Impairment is a broad term that covers a variety of mental challenges, including issues with decision-making, learning, and memory.

Trouble with executive function – the brain’s ability to coordinate thoughts and skills to problem-solve or make plans – can also be described as cognitive impairment.

Stroke can lead to various cognitive challenges that make everyday tasks frustrating. Simple things like planning the steps to make a meal can feel overwhelming or impossible after stroke.

Stroke survivors can also find it difficult to focus or pay attention because they’re easily distracted, a common sign of issues with executive function.

Although cognitive challenges caused by stroke are generally reported to be at their worst in the immediate months after stroke, they can improve over time.

My Cognitive Deficits After Stroke

I noticed significant changes in both my emotions and overall thought process in the years after stroke. I’ve often felt a step slower, struggling with indecision and understanding emotions from others.

These challenges were especially difficult during the first year of stroke recovery. However, they have improved over time and now, four years after stroke, they can be better described as minor inconveniences.

Decision Making

I’ve often been frustrated when planning a step-by-step process and thinking through decisions after stroke.

In the earliest weeks after returning home from rehab, I struggled with the most mundane decisions like simply what to do next.

I would be so indecisive as to whether I should go upstairs or downstairs to do something that I ended up pacing around the house, having an internal debate about where I should go and what to do next.

There were times that I was so unsure of what to do that I froze up, and my stroke-affected left side physically hurt. It was a dull ache that was uncomfortable and made walking feel more like a limp.

Grappling with indecision, there were many times when I wrote down all of my options in the hope that seeing my choices on paper would help me decide. Other times, I’d sit in meditation, hoping stillness would slow down my racing mind.

Understanding Emotions

Once I returned home and started going out in public again, I found it difficult to read people’s body language and understand how they might be feeling.

Simple things like maintaining a dinner conversation with friends or having an impromptu conversation on the street felt awkward to me.

I could follow and participate in the conversation, but without understanding the person’s tone of voice or reading their body language, I always felt like I was missing something.

Are they enjoying this conversation?

Are they ready to wrap things up and go our separate ways?

I couldn’t tell how they were feeling by their mannerisms. It was like reading a text message where you can only guess the emotional intent behind it.

My stroke was on the right side of my brain, which may help explain some of the challenges I faced since the right hemisphere is more involved in processing nonverbal communication.

Mental Health

Lastly, stroke can fundamentally change who we are, how we process information, and how we react to situations. Feelings of irritability, confusion, anger, and anxiety are common among stroke survivors.

I wrote a whole blog post on the emotional changes I noticed after stroke and shared some strategies that helped me work through them.

How to Overcome Cognitive Problems After a Stroke

Overcoming a slow thought process and indecision after stroke can be a frustrating experience.

However, like everything else with life after stroke, these challenges can improve and potentially become easier over time.

Here are a few strategies that have helped me, especially in the earliest months after stroke:

1 . Make Lists

Putting your thoughts on paper and planning out a to-do list is a tried-and-true method to ease distractions and prioritize.

2. Avoid Open-Ended Questions

For caregivers, friends, and family, don’t ask open-ended questions. Instead, focus on yes and no questions.

I picked up this suggestion from Debra Meyerson’s book Identity Theft, and it was such an eye-opener, I wish I had known about it sooner.

Narrowing down your question to a yes or no makes decision-making feel much less overwhelming for stroke survivors.

3. Plan Ahead

Similar to the first bullet point, plan ahead as often as possible. You can visualize scenarios that you may find yourself in and think about how you’ll react in certain situations.

Having a plan, as well as a plan B if things go awry, can help you avoid frustrating or confusing situations.

Understanding Cognitive Challenges After Stroke

While cognitive challenges caused by stroke are not visible like physical deficits, they still pose a substantial challenge in recovery.

Stroke survivors, as well as their family and friends, should practice patience as they learn to navigate a new post-stroke reality where they see the world around them differently and learn to work through cognitive issues post-stroke.