Cognitive rehabilitation

Improving at an on-screen task reliably improves that task. Carrying the gain into cooking, managing medication or returning to work needs the work to be done in those tasks, which is why occupational therapy sits inside this programme rather than next to it.

The written plan therefore names the activities, not the software.

Attention, working memory, processing speed, planning and insight are assessed separately, because they fail separately and a single score hides which one is the problem.

The result decides the order of work: attention before memory, memory before planning, because each one rests on the one before it.

The evidence here is weaker than the marketing around it. A Cochrane review of cognitive rehabilitation for attention after stroke found that divided attention may improve immediately after treatment (standardised mean difference 0.67, 95% confidence interval 0.35 to 0.98; 4 trials, 165 participants; low-certainty evidence), but no convincing evidence that the gain persists or reaches daily activities, mood or quality of life 1. For memory, a review of 13 trials with 514 participants found a short-term improvement in how patients rate their own memory, and none in objective memory testing 2.

For traumatic brain injury, a review of nine trials with 790 participants found insufficient good-quality evidence that cognitive rehabilitation improves return to work, independence in daily activities or quality of life 3. We state this because a programme sold on the promise of restored memory is selling something the research does not support. What is defensible is narrower and still worth doing: teaching strategies that work around the deficit, and practising the actual tasks the person needs to resume.

People whose attention, memory, planning or awareness is limiting independence after stroke, brain injury or neurosurgery, and who can sustain a structured session. In early dementia the goal changes: not restoring memory, but keeping routine, safety and daily activity in place for longer.

It does not suit someone still in an acute confusional state, or someone whose fatigue means a session cannot be completed — in both cases the programme is deferred rather than delivered badly. Where the main problem is mood rather than cognition, that is treated first, because depression after stroke depresses cognitive test scores as well.

Four to eight weeks, two to four hours a day, scheduled alongside physical rehabilitation rather than after it. The same instruments used at assessment are repeated at the end, so the change is measured on the same scale rather than described.

What usually moves first is the speed and consistency with which a familiar task is completed, not a test score. If neither has moved by the end of the block, the discharge report says so and the recommendation changes rather than the programme repeating unchanged.

Most of the real-world benefit comes from compensation rather than restoration: a diary that is actually used, alarms for medication, one task at a time, a kitchen arranged so that the order of work is obvious. These only hold if the household adopts them, so the family is trained alongside the patient.

The written home plan therefore names activities and not software: paying a bill, preparing a meal, planning a journey. Where return to work is the goal, the plan names the specific work tasks, because that is the level at which a gain either transfers or does not.