Screening, Assessment and Treatment Planning

A review of cognitive functioning should form part of assessment on treatment entry. This includes initial screening and management of acute causes of cognitive impairment (Wernicke’s encephalopathy, alcohol withdrawal delirium; see Chapter 22). If chronic and/or significant CI is suspected after management of these acute conditions, then a more thorough assessment by an appropriately qualified professional is indicated. This stepped mode of assessment is best practice for an environment marked by high rates of CI, limited staff time (particularly staff with specialist training in cognitive assessment, such as neuropsychologists), and limited health service budgets.  

Use of a standardised cognitive screening tool (such as the Montreal Cognitive Assessment; see Box 19.1 for an overview of cognitive screening tools) should be integral to any patient screening. Considering the myriad potential causes of cognitive impairment in people with AUD, assessment of current cognitive status should include history-taking of other risk factors for cognitive impairment (e.g. head injury, mental health conditions) in addition to physical health status. Evaluation of developmental and educational history (e.g. learning or intellectual disabilities, limited education) should be included; cognitive impairment may be incorrectly diagnosed if premorbid level of ability (e.g. literacy) is not taken into account. Clinicians should be particularly vigilant for those at high risk of demonstrating cognitive impairment - older (aged 50+) patients with a history of long-term heavy alcohol use and/or those with central nervous system (CNS) pathology such as head injury or epilepsy. 

The most widely used cognitive screening tool, the Mini-Mental State Examination (MMSE), while well validated for use in screening of early dementia, has limited sensitivity in detection of alcohol-related CI. The MMSE is copyright protected. The Montreal Cognitive Assessment (MoCA) is currently the most well-validated tool for use with individuals with AUD (See Box 19.1). Where possible, formal cognitive assessment should be deferred until the patient has achieved several weeks of abstinence to identify the highest level of performance. However, early cognitive screen and/or assessment is preferable to none at all and may be more robust with respect to establishing likely ongoing day-to-day impairments. A more comprehensive assessment of cognitive functioning (e.g. neuropsychological assessment) is recommended where cognitive impairment persists following extended abstinence (e.g. one to two months), and particularly when there are concerns about the impact of the CI on functioning (e.g. ability to return to work). The results of the assessment can inform appropriate AUD treatment and other interventions as required (e.g. need for guardianship, aged care or disability service involvement). Following full neuropsychological assessment, the clinician should discuss the results with the patient and their supporting networks and provide written material for patients in an easily understood format. It is important to include treating clinicians and support networks in this discussion as the patient themselves may lack the ability to retain knowledge of, or enact, recommendations. 

Box 19.1: Cognitive screening tools

  • Good reported sensitivity and specificity for CI in AUD populations
  • Assesses visuospatial/executive function, naming, attention, memory, language, abstraction, orientation
  • Alternate forms to limit practice effects with repeat administration
  • Paper or app formats
  • Multiple language versions
  • Freely available for non-commercial use
  • Can be administered by any healthcare professional who has appropriate training, with interpretation limited to a health professional with expertise in the cognitive field
  • Normative data sets available, including for adults aged 18 years and older
  • From September 2020, official training and certification in administration and scoring of the MoCA will be mandatory to access the test (exempt for students, residents, fellows and neuropsychologists). This currently costs $125 USD per person (discounts for groups offered)
  • May not detect mild CI or CI in highly educated individuals
  • The previous version (ACE-R), which has similar psychometric properties, has acceptable sensitivity/specificity in substance use disorder
  • Assesses attention, memory, fluency, language and visuospatial function
  • More detailed assessment of language and praxis functions than the MoCA; may be more suitable for clinical settings where comorbid substance use and neurodegenerative disorders are suspected
  • Alternate forms available to limit practice effects
  • Paper or app formats
  • Multiple language versions
  • Freely available for clinical practice and research
  • No mandatory qualification or training requirements
  • Requires further validation in AUD treatment groups
  • Longer administration time than the MoCA
  • Normative data lacking for younger (age <50) populations
20 - 30 MINS
  • Is able to detect CI in individuals with AUD
  • Assesses immediate and delayed memory, visuospatial/ constructional ability, language, attention
  • More detailed assessment of learning and memory skills than MoCA/ACE-III
  • Alternate forms available to facilitate repeated administration
  • Comprehensive normative data set 
  • Longer administration time than the MoCA or ACE-III
  • Does not assess executive function – this needs additional testing
  • Requires specific user qualifications (allied health or psychologist)
  • Costs $594 AUD for basic test kit 

Cognitive impairment can affect motivation, attention span, the capacity to critically evaluate situations and the ability to acquire new skills, but they can (indeed often do) improve after a period of abstinence from alcohol. Therefore, clinicians should take into account the possibility of improvement in cognitive functioning by allowing a sufficient period of abstinence from alcohol to elapse before finalising treatment planning. Establishing a routine may, however, mask cognitive impairment and if the routine is interrupted, the full extent of the impairment may manifest.

Chapter Recommendation Grade of recommendation
19.1 All patients should be screened for cognitive impairment on treatment entry. If cognitive impairment is suspected, comprehensive assessment should be conducted that includes medical review (including nutritional deficiencies, physical and psychiatric comorbidities), review of other risk factors for cognitive impairment (e.g. past head injury), and cognitive screening with a standardised tool (e.g. Montreal Cognitive Assessment). Neuropsychological assessment may be beneficial if cognitive impairment persists post an initial stabilisation period. A
19.2 Periodic re-evaluation of cognition (e.g. annually) in continuing patients is advised as impairment levels can fluctuate. Patients should be screened earlier if there are any inconsistencies in presentation or when people are not meeting their treatment goals/requirements. Using the same measure as at baseline is advised to be able to detect any changes in results. B
19.3 The possibility of improvement in cognitive functioning should be considered by allowing a sufficient period of abstinence (or substantial reduction of alcohol intake) to elapse before finalising treatment planning; the treatment plan should also address nutritional improvements and treatable co-existing medical conditions. Treatment planning should be undertaken in collaboration with the patient, as well as relevant supports (i.e., family and friends), and relevant health professionals (i.e., GPs, addiction medicine specialists). A