Stroke survivors, family members and caregivers become aware of behavioral changes more slowly than physical changes that accompany a right cerebrovascular accident. Some of these behavioral changes are subtle and may easily be misread. Like physical changes such as hemiparesis (weakness on one side of the body) or speech difficulties, behavioral changes can have a profound impact on the survivor and those around them.

The right hemisphere was once called the silent hemisphere, implying that its function was less important than that of the left hemisphere. It is still referred to as the non-dominant hemisphere, but as researchers and clinicians continue to learn more about the brain, the right hemisphere’s importance grows. Damage to the right hemisphere alters life patterns as surely as damage to the left hemisphere. Behavioral and cognitive changes that accompany a right cerebrovascular accident include anosognosia, lack of initiation, easy fatigue, rigid inflexibility and reduced frustration tolerance. While everyone may experience any or all of these symptoms from time to time they may be more pronounced or frequent in the stroke survivor.

• Anosognosia–lack of knowledge of self. We all see ourselves differently than we are seen by others. We may overestimate our abilities or sell ourselves short. I have at times “bitten off more than I can chew” and made promises which were difficult to keep. I have at times not trusted my abilities and balked at opportunities.

We all struggle from time to time knowing our limitations. Interestingly, the right side of our brain manages this task. We learn, in part from trial and error and in part from judgment what our limitations and abilities are. Often a right cerebrovascular accident injures the part of the brain that helps us accurately judge our abilities.

The stroke survivor may cognitively estimate their abilities to be the same or similar as before the stroke. They literally lack the ability to assess themselves accurately and don’t know it. There is inherent danger in this problem. Initially the survivor may overestimate their physical ability and increase the likelihood of a fall. It seems that the physical limitations are learned more rapidly than the cognitive. Survivors may firmly believe they can return to their pre-stroke level of function relating to work or managing affairs when they, in fact, need support and assistance.

The survivor’s job is to compensate and trust. First, recognize this as a potential problem. Second, solicit feedback from trusted friends, loved ones and professionals. Return to pre-stroke activities in a stepwise fashion. Test your limits with someone reviewing your work. Undertake less than you think you can and have it checked. Keep adding to the job until you reach your limit. Keep checking your limits and increase them as appropriate.

• Initiation–the ability to spontaneously start a task. One of the roles of our brain is to cue or remind us in a timely fashion to begin a task. Many times I have been engaged in an activity such as reading or writing and have spontaneously recalled that I planned to perform another task. I remembered the need to make a phone call or visit with a patient. My brain was aware of the time, the task I was engaged in and the task I needed to do and cued me. My brain spurred me on to change directions and start the next task.

If the brain does not perform this function consistently, the stroke survivor may find that many tasks do not get completed. The people around them may interpret these missed jobs as lack of caring, laziness or depression. If the survivor’s brain is inconsistent in self-cueing, the survivor can compensate. A system of external reminders or cues may be developed. The system can be as complex as a computerized palm pilot or as simple as phone calls from a loved one at designated times to remind the survivor of the next task. A behavioral specialist, occupational therapist or speech pathologist can be enlisted to assist in the development of the most efficient system.

• Rigid inflexibility–the ability to deviate from a plan, course of action or a thought process is flexibility. We all need to be able to change our minds and alter our plans from time to time.

Stroke survivors may have more difficulty in recognizing the need to change their plans or ideas. Rigid inflexibility may be misinterpreted as just plain stubbornness. Careful planning for a day’s activities (don’t overdo), and not deviating from the plan will help reduce the conflict that changes may cause. Backing away from a task that is not going well, or asking for a different way of looking at the task may save time and energy.

• Fatigue–Almost universally, stroke survivors find they don’t have as much energy. They also report that, in addition to getting tired faster, they have very limited reserves. When they run out of energy it becomes extremely difficult to carry on. It has been described as running into a brick wall.

Survivors also may have difficulty judging how much energy is left and find themselves in situations with no more energy to draw upon. The brain weighs about 3 pounds (about 2% of the body weight of a 150 pound person) and it uses 20% or more of the oxygen and nutrients the body needs. Energy conservation becomes very important. Fatigue increases the likelihood that mistakes will be made.

Planning a day’s activities carefully and avoiding overexertion is essential. Also recognizing a busy week and building in breaks can be helpful. Daily relaxation or meditation is recommended. Routines such as getting up and going to bed everyday at the same time are great energy savers. Change in routine costs energy.

• Reduced frustration tolerance–getting angry or upset more easily. Life continually presents obstacles, which can be frustrating. A cerebrovascular accident provides its own set of frustrations. While we all get frustrated from time to time, a survivor may find that management of strong emotions is more difficult. Managing energy, as well as good daily planning, can help avoid frustrating situations. Label situations that are frustrating and attempt to avoid them.

Right cerebrovascular accidents bring a host of other behavioral difficulties such as depression and difficulty socializing. Adapting to improving quality of life is critical. If problems surface, talk about them with loved ones and caregivers. Support groups can be extremely helpful. Don’t ignore these difficulties as they will keep interfering with life. Improving quality of life is possible. All it requires is careful planning and loving attention.