How Screening for Cognitive Deficits Leads to Improved Substance Abuse Interventions

Substance abuse and withdrawal can trigger mental disorders that are temporary—lasting up to a month after abstinence—or more permanent. One study found that 31% of patients using alcohol, cannabis, or stimulants scored below the cognitive impairment threshold for memory and visuospatial abilities. Prevalence studies conducted at residential rehabilitation facilities have found 52 to 80% of patients checking in had some form of cognitive impairment.

Neurocognitive disorders can not only adversely affect cognition, but lead to relapses when treatment protocols are overly complex. Adequate care for patients with co-occurring substance abuse and cognitive deficits requires a multidisciplinary team who understands how to increase success rates in this specific cohort.

Interventions for patients with substance abuse and cognitive deficits

Patients with a substance abuse disorder who are also struggling with a cognitive deficit differ from patients who may be experiencing short-term psychological distress like anxiety, paranoia, depression, or attention deficits that often accompany withdrawal. Individuals with permanent cognitive impairments may have difficulty remaining abstinent due to distractibility and lack of insight. They may grapple with processing complex instructions and coping with the rigors of long-term recovery.

However, there are many ways clinicians can help patients understand and navigate this situation, such as:

• Explaining what substance use related impairment means.
• Educating clients with step-by-step life skills training.
• Encouraging patients to allow ample time to complete tasks, recheck their work, and use memory aids.
• Showing patients how to use alarms, voice recorders, notepads, calculators, and calendars.
• Helping to establish cues to remember information and daily living routines.
• Teaching how to make cost-benefit analysis lists as part of the decision-making process.
• Developing practical daily living routines to aid in functioning.
• Considering the use of cognitive enhancing medicines, exercise, and transcranial magnetic stimulation.
• Assuring clients it’s okay to ask for help when needed.
• Referring clients for psychological assessment and treatment of specific mental disorders.

Adjustments to Help Substance Abuse Patients with Cognitive Deficits

Behavioral interventions are rarely one-size-fits-all, so it helps to assess the level of cognitive functioning before starting a new treatment protocol. Practitioners may consider:

• Scheduling sessions that are shorter, but more frequent.
• Using multiple modes for communication (including oral, visual, auditory).
• Engaging in positive, strength-based feedback approaches that offer immediate, direct benefits.
• Repeating information and asking clients to paraphrase.
• Supporting the use of humor, mindfulness, or hobbies as coping strategies.
• Coordinating with care teams that may include neurological doctors, vocational services, or specialists.

MoCA picks up on substance abuse disorder related cognitive impairment

Most clinicians have used MoCA to specifically screen for cognitive impairments, but one of the lesser-known use cases is to screen substance use disorder patients to predict the likelihood of a successful intervention. Clinicians will better understand their patients by separating short-term psychological distress from long-term substance abuse-triggered cognitive decline.

Multiple peer-reviewed studies validate the use of MoCA for cognitive screening in substance abuse cases:

• “Substance Use Disorder (SUD) patients should routinely be screened for cognitive impairment, as it predicts dropout. Screenings should be ensued by appropriate adaptations to treatment and further assessment. The MoCA is a useful screening tool for this, independent of psychological distress. Future studies should replicate our findings, investigate specific interventions, and establish SUD population norms for the MoCA.” MoCA can be a more sensitive screening tool than other methods like the SCL-10. In this study, researchers found patients scoring below the MoCA cut-off rate had a higher risk of dropping out of treatment programs, even if they were not exhibiting outward signs of psychological distress and passed the SCL-10. ¹
• “These findings indicate that the MoCA provides a time-efficient and resource-conscious way to identify patients with SUDs and neuropsychological impairment, thus addressing a critical need in the addiction treatment research community.” Scientists studied the 10-minute MoCA screening test compared to the widely recognized 45-minute Neuropsychological Assessment Battery-Screening Module and found 75% agreement. The MoCA showed 83.3% sensitivity and 72.9% specificity for the identification of cognitive impairment.²
• “Our findings are consistent with previous research showing that MoCA provides a time- and resource-efficient assessment for identifying MCI in patients with SUD. Our study indicates that the results of the MoCA are independent of concurrent psychological distress, while the BRIEF-A GEC is significantly associated with psychological distress, as  measured by the SCL-90-R. We, therefore, suggest that performance-based assessment, such as the MoCA, could reduce the influence of psychological distress on cognitive screening.” In this study, 34/6% of participants scored below the threshold for cognitive impairment in patients with Substance Use Disorder. Researchers found a significant correlation between the SCL-90R GSI score and the BRIEF-A GEC, but no significant correlation between those tests and MoCA. In other words, MoCA is a more objective scale for multi-drug users, as it reduces the impact of psychological distress in screening compared to traditional tools³
• “A positive MoCA screening for cognitive impairments among post-detoxification Severe Alcohol Use Disorder (SAUD) patients could also be related to comorbid agoraphobia and depressive episodes rather than to SAUD itself. A comprehensive psychiatric assessment must be performed in SAUD patients so that other potential causes of cognitive deficits, in particular with regard to mood and anxiety disorders, can be identified and treated.” Researchers looked at 100 recently detoxified patients with SAUD and found that MoCA was effective at identifying subjects with cognitive deficits, which could reduce the efficacy of therapeutic interventions, potentially resulting in dropout and relapse.⁴

Due to the significant link between substance abuse disorder and cognitive impairment, MoCA is a useful screening tool in the treatment toolkit. Its relative sensitivity can help flag potential issues that may arise in treatment interventions sooner rather than later.

References:

1 Sømhovd, M., Hagen, E., Bergly, T., & Arnevik, E. A. (2019). The Montreal Cognitive Assessment as a predictor of dropout from residential substance use disorder treatment. Heliyon, 5(3), e01282. https://pubmed.ncbi.nlm.nih.gov/31025003/

2 Copersino, M. L., Fals-Stewart, W., Fitzmaurice, G., Schretlen, D. J., Sokoloff, J., & Weiss, R. D. (2009). Rapid cognitive screening of patients with substance use disorders. Experimental and clinical psychopharmacology, 17(5), 337. https://pubmed.ncbi.nlm.nih.gov/19803633/

3 Egon Hagen, Mikael Sømhovd, Morten Hesse, Espen Ajo Arnevik, Aleksander H. Erga,. Measuring cognitive impairment in young adults with polysubstance use disorder with MoCA or BRIEF-A – The significance of psychiatric symptoms. Journal of Substance Abuse Treatment, Volume 97, 2019, Pages 21-27. https://pure.au.dk/ws/files/140318722/Measuring_cognitive_impairment_in_young_adults_with_polysubstance_use_disorder_with_MoCA_or_BRIEF_A.pdf

4 D’Hondt, F., Lescut, C., Maurage, P., Menard, O., Gibour, B., Cottencin, O., … & Rolland, B. (2018). Psychiatric comorbidities associated with a positive screening using the Montreal Cognitive Assessment (MoCA) test in subjects with severe alcohol use disorder. Drug and Alcohol Dependence. https://psycnet.apa.org/record/2018-47161-033

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