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Cognitive Remediation/Rehabilitation

Cognitive rehabilition/cognitive training methods have been proposed as an intervention to restore and/or increase cognitive functioning in individuals with alcohol use disorder and potentially address impacts on treatment. There is some evidence of improved cognitive functioning in specific domains (e.g. executive functions, working memory) after use of cognitive remediation methods in individuals with substance use disorders. Moreover, combination of treatments, such as cognitive bias modification and goal management training have also been shown to increase cognitive outcomes, although there is insufficient evidence to date to recommend any one strategy. Additionally, while there is some consistency in the effectiveness of the approaches for the skill being trained, the extent of improvement in clinical outcomes, such as reduced relapse rates, is unclear. Cognitive recovery after abstinence also plays a large role in the improvements seen in these studies. More systematic evidence by way of larger RCT studies using AUD individuals only is required, along with clearer evidence of improvement in long-term drinking outcomes and transfer of cognitive skills to broader recovery, in order to better elucidate the lasting effects of these techniques. 

Box 19.2: Possible treatment adaptions for individuals with cognitive impairment

COGNITIVE WEAKNESS: ATTENTION

POTENTIAL EVERYDAY IMPACT 

  • Short concentration span
  • Easily distracted
  • Problems following conversations/long instructions
  • Tires easily

POTENTIAL STRATEGIES

  • Limit environmental distractions (e.g. take to private, quiet room)
  • Simplify and shorten discussions – focus on one or two main points
  • Break tasks down into steps (e.g. use list and work through sub-steps)
  • Monitor fatigue, take frequent breaks
  • Shorten length of sessions

COGNITIVE WEAKNESS: SPEED OF INFORMATION PROCESSING

POTENTIAL EVERYDAY IMPACT

  • May take longer to respond to questions or perform tasks
  • Difficulty taking in lengthy, rapid or complex information
  • May react slowly in response to situations

POTENTIAL STRATEGIES

  • Slow delivery of information to a rate that matches the individual’s speed
  • Give plenty of time for patient to respond and complete tasks. Be patient
  • Break information up into small components and address one thing at a time
  • Expect the individual to require more time to benefit from interventions
  • Coach patients in strategies which allow them more time for decision-making (e.g. taking time out)

COGNITIVE WEAKNESS: LEARNING AND MEMORY (MILD DEFICITS)

POTENTIAL EVERYDAY IMPACT

  • Difficulty learning and retaining new information
  • Problems retaining what has been discussed previously
  • Missed appointments

POTENTIAL STRATEGIES

  • Set an agenda at each meeting (e.g. dot points) and refer to this during session
  • Present information in a number of ways – verbal, visual aids, doing with patient
  • Repeat information and ask patient to put in own words to check understanding
  • End session with a verbal and written summary
  • Provide structure and routine (e.g. appointment same time on the same day)
  • Encourage use of a diary/phone calendar/phone alarms
  • Send reminders for upcoming appointments (e.g. via SMS or phone call the day before)
  • Use name tags for staff

COGNITIVE WEAKNESS: LEARNING AND MEMORY (SEVERE DEFICITS)

POTENTIAL EVERYDAY IMPACT

  • Inconsistent accounts of behaviour (e.g. last drink)
  • Difficulty providing important details, including personal history, medical history, patterns of substance use
  • Confabulation

POTENTIAL STRATEGIES

  • Utilise external supports to facilitate engagement (e.g. transport to appointment)
  • Consider heavily structured treatment options (e.g. AA groups, inpatient)
  • Avoid treatments reliant on new learning of cognitive skills (e.g. CBT)
  • Consider engagement with social activities that minimise memory (e.g. drop-in groups)
  • Support planning with use of timetables, weekly planners, reminders for appointments
  • With the individual’s consent, seek to obtain information from an informant (e.g. family memory or caregiver) to corroborate and fill in key historical details

COGNITIVE WEAKNESS: EXECUTIVE DYSFUNCTION

POTENTIAL EVERYDAY IMPACT

  • Repetitive in words and actions
  • Trouble multitasking
  • Difficulty executing a complex task with multiple steps
  • Concrete in thought
  • Difficulty generating alternative solutions to problems
  • Difficulty applying learnt information to other situations
  • Difficulty thinking from the perspective of others
  • Poor impulse and/or emotional control
  • Reduced insight into behaviour

POTENTIAL STRATEGIES

  • Use concrete examples and role plays rather than abstract concepts
  • Encourage pre-planning of steps involved in a task
  • Brainstorm potential problems in advance
  • Provide clear and consistent boundaries and consequences for behaviour
  • Reinforce positive behaviour (e.g. verbal affirmation, rewards)
  • Encourage behavioural strategies (e.g. breathing exercises)
  • Coaching self-talk strategies can also help to manage behaviour (e.g. ‘stop, think, do’)
  • May need assistance and support to understand and complete complex forms
  • Consider role of Guardianship, Financial Management, Involuntary Treatment
  • Reduce exposure to behavioural triggers (e.g. access to alcohol)
  • Verify information where important with a reliable informant
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