Routine Predictability

After a brain injury, a daily routine that is consistent and predictable can alleviate cognitive fog and anxiety. Anxiety is triggered by the brain's neurobiological response to uncertainty as described by Grupe and Nitschke103 and can significantly be reduced by a simple, structured routine called habits. Cicerone et al104 established that a structured and regular daily cognitive routine is a helpful therapy method for improving executive function and cognitive fog. Wood and Rünger105 supported this premise by pointing out how habituation removes the need for executive function from the brain and makes routine actions automatic, which reduces cognitive load. Decision fatigue can impair a brain already coping with the trauma of brain injury. Vohs et al106 noted that removing the need to make basic decisions allows the mind to reserve energy for other cognitive tasks instead of depleting it.

Having a morning routine allows patients to wake up and begin the day without the added stress that might be encountered later in the day. Simple habits like making the bed, reviewing the calendar and the to-do list for the day while enjoying a morning juice, eating a healthy breakfast and completing light stretching or exercise are brain-healthy ways to start a day feeling accomplished. These morning activities are supported by behavioral activation, which Ekers et al107 found provides a sense of accomplishment after completing scheduled events and can be used to reduce depressive tendencies following brain injury. A simple act of making the bed in the morning provides a small victory and sets a sense of control for the rest of the day. The habit of reviewing the calendar and to-do list every morning helps to set the structure for getting the patient's day started. Masicampo and Baumeister108 found that setting up goals and writing them down frees up resources in the brain. Having a simple and consistent routine gives the patient accomplishments. 

Observing both the sunrise and the sunset in a daily schedule can be a predictable daily event to anchor habits around. Establishing habits and routines around these natural events reinforces the body's circadian rhythm, provides a more consistent wake-up and sleep schedule, and gives stability throughout rehabilitation.109-110 Wright et al109 showed that a natural light-dark cycle was the strongest cue in triggering circadian rhythm patterns. Light synchronization has also been explored by LeGates et al110, finding that natural light environments act as an important stabilizing factor for overall mood and cognitive function. 

A calming evening routine sends the signal to the brain that it is time to wind down for the evening. Evening habits might include washing dishes, turning the lights off, writing a journal, getting ideas onto sticky notes and setting the alarm for the next morning. Harvey111 showed that unmanaged presleep cognitive stimulation causes insomnia, leading the brain to be kept from transitioning into a healthy, restorative sleep state. 

Clinicians can have patients write down their thoughts or worries during the evening so they can be released from the mind before bed. Risko and Gilbert112 described this concept as cognitive offloading, establishing that the use of an external physical medium reduced the patients need to keep track of tasks in the mind. In overnight sleep studies, Scullin et al113 validated this by finding that writing down a to-do list for the following morning reduces delay to sleep compared to just thinking about the tasks at hand. 

Writing down thoughts, worries and reflections of the day in a journal can be a powerful way for patients to process the events of the day and clear the mind for nighttime. This habit can support patients in better processing the day, letting go of anxieties or fears and preparing their brain for a restorative sleep. Baikie and Wilhelm114 observed that writing contributed in the cognitive processing of stressful thoughts. By offloading thoughts through journaling, the patient signals their brain to let go of the day's cognitive load and begin restorative sleep at night.

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