Cognitive changes with ARBI can include

• Poor initiation and lack of motivation
• Rigid and inflexible thinking and behaviour
• Difficulty in abstract reasoning
• Inability to deal with novelty, solve new problems or adapt to change
• Lack of self-awareness, realistic self-appraisal and evaluation

Disorders Of Awareness

Disorders of awareness are perhaps the most frustrating and complicated aspects of ARBI.They are closely related to brain impairment, particularly frontal lobe dysfunction, but may also reflect emotional difficulties in adjusting to disability.
Common disorders of awareness include:

• Denial of Disability - Reflects a defence mechanism associated with psychological adjustment to disability
• Poor Insight - Ranges from being unaware of one's impairment to being aware of the disability, but not appreciating its implications
• Apathy - People with ARBI may appear unconcerned about their impairment
• Rationalisation - When faced with feedback about cognitive impairment, many people with reduced insight formulate elaborate excuses to explain away their problems and behaviour

These symptoms of brain impairment will help you identify people who may require assessment for ARBI.

Other Problems Related To ARBI

Thinking difficulties can make other problems worse. They can cause:

• Anxiety and depression
• Suspicious or paranoid behaviour
• Problems in dealing with and controlling anger
• Reduced frustration tolerance
• Confusion

Some skills are preserved

Many functions may remain unaffected by ARBI, including:

• Immediate memory and basic concentration
• Vocabulary and language - verbal expression, understanding of language, reading and writing, holding conversations
• Long term memory
• Well-learned skills, such as driving, making a cup of tea, brushing teeth, playing tennis, doing calculations and skills required for working
• Knowledge of facts and understanding of the world
• Knowledge of the social world - well-learned social skills, manners and pleasantries
• Everyday procedures of daily living
• Intellectual functions - but the person's capacity to apply their knowledge and skills can be affected

The preserved or unaffected cognitive functions can mask ARBI to health workers, the person and their family.

Memory impairment

There are three types of memory:

Immediate Memory - Short pieces of information held for a matter of seconds are stored in immediate memory. For example, the ability to repeat back information immediately or hold a conversation relies on immediate memory.

Short Term Memory - To lay down a permanent memory trace, information is stored in short term memory. Short term memory capacity is a person's ability to form new memories, learn new skills and information, and retrieve information when it is needed. Short term memory allows people to remember things from day to day, or week to week.

Long Term Memory - Sometimes termed remote memory, long term memory stores information, events, knowledge and skills acquired in the past. For example, life events (including childhood memories), reading and writing ability, words and vocabulary, and skills learned at work (amongst many others) all make up long term memory.

Memory Impairment and ARBI

Immediate memory is not usually affected by ARBI. Those with ARBI commonly experience problems with:

• Learning new information
• Retrieving information stored in memory
• Remembering recent events or recently acquired information
• Confabulation - the fabrication of memories as a response to inability to remember
• Retrograde Amnesia - after the onset of ARBI there may be a period in the person's life of which they have little or no recall. The gap in the person's life may become larger as time passes. For example, the person may have difficulties giving information about the last ten years, but have excellent recall of events prior to this time.

Frontal Lobe Dysfunction

The Frontal Lobes and the Executive System

The role of the brain's frontal lobes can be likened to the role of a managing director (MD) of a large corporation. The workers have highly specialised expertise and roles they individually attend to, but someone needs to be responsible for over seeing the company's operations. The MD is responsible for setting goals for the company, coordinating and supervising employees, forward planning, monitoring and evaluating performance, dealing with problems and making complex decisions.

Similarly, the frontal lobes are responsible for coordinating other cognitive functions of the brain.

Frontal Lobe Dysfunction and ARBI

An early sign of ARBI is the deterioration of ability to plan, organise and solve problems. Frontal lobe dysfunction may result in:

• Difficulties in planning ahead and using foresight
• Difficulties in organising information and behaviour
• Inability to foresee consequences of one's actions
• Difficulties monitoring, regulating and controlling behaviour, leading to impulsive and disinhibited behaviour
• Inability to learn from errors and change behaviour