Neuropsychological performance and treatment outcome in male alcoholics

Neurocognitive Functioning and Treatment Outcome Following Detoxification Among Asian Alcohol-Dependent Inpatients

BACKGROUND

The prevalence of alcohol use disorders in Asia is increasing and relapse among treated populations remains the norm, not the exception. The extent to which cognitive impairment influences clinical outcome remains unclear, with research dominated by studies of Caucasian populations.

OBJECTIVES

This study examines behavioral and self-reported cognitive functioning in detoxified alcohol-dependent (AD) patients in Singapore and its association with outcome.

METHODS

The cognitive performance of 30 recently-detoxified AD inpatients and 30 demographically-matched controls was compared using visuospatial memory, working memory, set-shifting, planning and reflection impulsivity tests of the CANTAB®, and self-reported dysexecutive symptoms and everyday cognitive difficulties. Patients' alcohol use and self-reported cognitive functioning were reassessed 3-months post-discharge.

RESULTS

Compared to matched controls, AD inpatients exhibited significantly poorer fluid intelligence, visuospatial memory, working memory, set-shifting flexibility and planning/organization, but not reflection impulsivity. In support of Western studies, a significant proportion (three-quarters) were "clinically impaired" on subtests. Significant reductions were observed in alcohol units, frequency and dependency scores at follow-up, though improvements in self-reported cognitive functioning were limited to abstainers. Baseline cognitive performance did not differentiate those who had abstained from alcohol and relapsed at follow-up.

CONCLUSIONS/IMPORTANCE

Memory and executive functioning impairments were evident among Asian AD patients alongside self-reported cognitive difficulties, thus cognitively demanding psychological interventions may have limited impact during early detoxification. Future studies can build on these findings, with larger samples and measurement of moderating and mediating factors to extend our understanding of how cognitive impairment influences outcome.

Patient predictors of alcohol treatment outcome: a systematic review

Patient characteristics as predictors of alcohol use disorder treatment outcome were examined on three levels, identifying whether or not variables were significant predictors of drinking-related outcome in univariate analysis, in multivariate analysis, and in multivariate analyses limited to studies including several "key predictors." Also, a model was developed to predict total percentage of variance in treatment outcome accounted for in each study using each of the key predictors and a range of methodological factors. The most consistent univariate predictors were baseline alcohol consumption, dependence severity, employment, gender, psychopathology rating, treatment history, neuropsychological functioning, alcohol-related self-efficacy, motivation, socioeconomic status/income, treatment goal, and religion. When these key predictors were combined into multivariate analyses, baseline alcohol consumption and gender showed substantial reductions in predictive consistency whereas the remaining variables were not greatly affected. The most consistent predictors overall were dependence severity, psychopathology ratings, alcohol-related self-efficacy, motivation, and treatment goal. The two predictor variables most associated with greater variance accounted for in predictive models, when controlling for broader methodological variables, were baseline alcohol consumption and dependence severity. Few predictor variables were examined in more than a third of studies reviewed, and few variables were found to be significant predictors in a clear majority of studies. However, a subset of variables was identified, which collectively could be considered to represent a consistent set of predictors. Too few studies controlled for other important predictor variables. Attempts to synthesize findings were often hampered by lack of agreement of the best measure for predictor variables.

Cognitive impairment influences drinking outcome by altering therapeutic mechanisms of change

Serious neuropsychological impairments are seen in a minority of addiction treatment clients, and, theoretically, these impairments should undermine behavioral changes targeted by treatment; however, little evidence supports a direct influence of impairment on treatment response. To address this paradox, the authors used structural equation modeling and Project MATCH data (N=1,726) to examine direct, mediated, and moderated paths between cognitive impairment, therapeutic processes, and treatment outcome. Mediated relations were found, wherein impairment led to less treatment compliance, lower self-efficacy, and greater Alcoholics Anonymous Involvement, which, in turn, more proximally predicted drinking. Impairment further moderated the effect of self-efficacy, making it a poor predictor of drinking outcomes in impaired clients, thereby suggesting that impaired and unimpaired clients traverse different pathways to addiction recovery.

Cognitive impairment influences drinking outcome by altering therapeutic mechanisms of change

Serious neuropsychological impairments are seen in a minority of addiction treatment clients, and, theoretically, these impairments should undermine behavioral changes targeted by treatment; however, little evidence supports a direct influence of impairment on treatment response. To address this paradox, the authors used structural equation modeling and Project MATCH data (N=1,726) to examine direct, mediated, and moderated paths between cognitive impairment, therapeutic processes, and treatment outcome. Mediated relations were found, wherein impairment led to less treatment compliance, lower self-efficacy, and greater Alcoholics Anonymous Involvement, which, in turn, more proximally predicted drinking. Impairment further moderated the effect of self-efficacy, making it a poor predictor of drinking outcomes in impaired clients, thereby suggesting that impaired and unimpaired clients traverse different pathways to addiction recovery.

Performance of recently detoxified patients with alcoholism on a neuropsychological screening test

OBJECTIVE

Early in recovery from alcoholism, cognitive deficits may compromise patients' utilization of rehabilitative information. Cognitive impairment in a sample of newly detoxified inpatients with alcoholism was examined using the Neurobehavioral Cognitive Status Examination (NCSE).

METHODS

Consecutively admitted psychiatric inpatients (N=233) with an alcohol-related primary diagnosis (63% male, mean age 46.3) were administered the NCSE following medical stabilization. Within-samples differences between age and diagnostic groups were examined and scores were compared to normative samples.

RESULTS

Inpatients older than 50 demonstrated significant cognitive deficits for all scales except Attention. In comparison with normative samples, patients with alcoholism produced lower scores, with the most pronounced deficits among middle-aged patients. In alcohol-abusing patients with medical comorbidities, language deficits and more severe memory deficits were observed. Abuse severity or comorbid psychiatric disorder produced no differences in NCSE scores.

CONCLUSIONS

Neuropsychological screening following detoxification in patients diagnosed with an alcohol disorder reflected the effects of increased age and medical comorbidity. Our finding of frequent deficits in abstraction, comprehension, and memory suggests that cognitive-behavioral treatments for inpatients may be less effective if cognitive impairment is not considered.

Neurocognitive impairment associated with alcohol use disorders: implications for treatment

Between 50% and 80% of individuals with alcohol use disorders experience mild to severe neurocognitive impairment. There is a strong clinical rationale that neurocognitive impairment is an important source of individual difference affecting many aspects of addiction treatment, but empirical tests of the direct influence of impairment on treatment outcome have yielded weak and inconsistent results. The authors address the schism between applied-theoretical perspectives and research evidence by suggesting alternative conceptual models of the relationship between neurocognitive impairment and addiction treatment outcome. Methods to promote neurocognitive recovery and ways in which addiction treatments may be modified to improve psychosocial adaptation are suggested. Specific suggestions for future research that may help clarify the complex relations between neurocognitive impairment and addiction treatment are outlined.

Factors Affecting the Short-Term Prognosis of Alcohol Dependent Patients Undergoing Inpatient Detoxification

Stable measures of psychological functioning require a considerable period of abstinence. However, the duration of inpatient detoxification programs has decreased dramatically in most health care systems, posing a novel challenge for clinical evaluation of patients. The present study was carried out to examine whether factors predicting short-term prognosis can be identified in alcohol dependent subjects during early stages of inpatient detoxification. Self-reports of mood states were obtained, and executive cognitive functioning was examined. Outcome was studied at 2-3 months. No correlation was found between self-reported symptoms of depression, hopelessness, and anxiety, and percentage of nondrinking days. A significant positive correlation was found between Wisconsin Card Sorting Test (WCST) performance and short-term prognosis measured by this parameter. Thus, in addition to transient withdrawal-related effects, impairments of WCST performance in early stages of alcohol detoxification may reflect more long standing deficits in problem-solving strategies, of possible relevance for matching patients to treatment services.

Out-patient behaviour therapy in alcoholism: impact of personality disorders and cognitive impairments

OBJECTIVE

We investigated whether alcoholic patients with comorbid personality disorders and those with cognitive impairments would benefit in a different way from different behaviour therapy strategies.

METHOD

After detoxification, 120 alcoholics were assigned randomly to one of three out-patient treatment programmes comprising 'coping skills training', 'cognitive behaviour therapy' or unspecific supportive control therapy. Personality disorders and cognitive impairments were assessed at the beginning of the 6-month treatment period.

RESULTS

The impact of concomitant personality disorders or cognitive impairments was generally only moderate and mainly independent from treatment condition. However, alcoholic patients relapsing within 6 months after detoxification showed a higher rate of personality disorders (especially antisocial and borderline) and slightly more cognitive deficits (especially in verbal memory and visuomotor functions) than abstainers even before therapy.

CONCLUSION

The high amount of early relapses and drop-outs probably hindered larger differentiated treatment effects. Hypotheses will be retested in treatment completers using forthcoming follow-up data.

Auditory P3a assessment of male alcoholics

BACKGROUND

P3a amplitude differences between alcoholic and control groups have not been well defined. Because event-related potential (ERP) differences between these groups appear to be influenced by task difficulty, the present study employed a new auditory ERP paradigm, in which target/standard tone discriminability was difficult, with infrequent nontarget stimuli used to elicit the P3a.

METHODS

A total of n = 27 male alcoholics and n = 25 male controls were assessed using a three-tone discrimination paradigm, in which the discriminability between the target and standard was difficult, with easily discriminable infrequent nontarget tones also presented. A P3a component with a centro-frontal maximum to the rare nontargets and a P3b with a parietal maximum amplitude to the target stimulus were obtained. Current Source Density (CSD) maps were derived from the potential data and employed to assay topographical differences between subject groups.

RESULTS

Alcoholics produced smaller P3a amplitudes than control subjects to the rare nontargets with no peak latency differences observed. The most prominent current sources are apparent more anteriorly for the nontarget compared to the target stimulus in both groups. There were more sources and sinks in the alcoholics than in the control subjects for P3a. A bootstrap analysis method showed that P3a CSD maps evinced distinct topographic distributions between alcoholics and control subjects in all brain regions.

CONCLUSIONS

The lower P3a amplitude and weaker sources in alcoholics coupled with less topographic specificity in their CSD maps, suggests disorganized inefficient brain functioning. This global electrophysiological pattern suggests cortical disinhibition perhaps reflecting underlying CNS hyperexcitability in alcoholics.

Verbal ability predicts abstinence from drugs and alcohol in a residential treatment population

Measures of cognitive ability, depression, anxiety, antisocial personality, as well as length, type and severity of addiction were obtained from 122 substance abusers enrolled in residential treatment programs. Over a subsequent 6-mo. monitoring period, relapse to substance use was detected in 46 subjects. 17 subjects withdrew from treatment for other reasons and their relapse status was unknown. The remaining 59 maintained abstinence from alcohol or drug use throughout the monitoring period. The only variables to differentiate the groups significantly on outcome were IQ and the Verbal subtest from the Shipley Institute of Living Scale. Stepwise discriminant function analysis indicated that the Verbal component alone correctly identified 64.4% of patients who would successfully remain abstinent.

Cognitive rehabilitation of chronic alcohol abusers

The current literature suggests that individuals who chronically abuse alcohol exhibit a wide variety of cognitive deficits resulting from cerebral dysfunction that is either directly or indirectly related to their alcohol consumption history. Cognitive deficits have been hypothesized as having implications for standard alcohol treatment efficacy as they may directly affect cognitively impaired individuals' abilities to utilize various treatment modalities. Although evidence is accumulating that suggests this is actually the case, the majority of alcohol treatment programs neither directly consider the impact cognitive deficits have on treatment efficacy nor do they employ cognitive rehabilitation treatment strategies to remediate identified cognitive deficits. Few studies exist that investigate the remediability of neurobehavioral deficits or the efficacy of integrating cognitive rehabilitation strategies into more traditional treatment programs. Empirical investigations conducted to date indicate that some cognitive deficiencies secondary to alcoholism are amenable to cognitive rehabilitation and this remediation is generalizable. Rigorous well-controlled treatment outcome investigations are needed in order to determine the efficacy of cognitive rehabilitation techniques in naturalistic settings using ecological outcome measures. Also, emphasis should be placed on integrating cognitive rehabilitation techniques with proven efficacy into traditional alcoholism treatment programs.

Perceptuomotor function of homeless males in alcohol rehabilitation

In a sample of 76 alcohol rehabilitation program (ARP) residents, homeless men demonstrated significantly poorer perceptuomotor function than nonhomeless men. This difference persisted despite similarities in several factors associated with neurobehavioral test scores including demographic characteristics; frequency, quantity, and duration of alcohol and other substance use; psychosocial factors, including motivation and social support; health, including history of head trauma; and neurotoxic occupational exposure.

Electroencephalographic and autonomic predictors of relapse in alcohol-dependent patients

Measures of electroencephalographic and autonomic activity were recorded from 17 alcohol-dependent patients (after 7-10 and 14-17 days of abstinence) and 14 age-matched non-drug-dependent controls (after comparable intervals). The alcohol-dependent group was divided into subgroups of abstinence-prone or relapse-prone patients, based on their 3-month posttreatment outcome. Data analyses revealed that relapse-prone patients evidenced more electroencephalographic beta-activity at the vertex lead, and a larger amplitude carotid pulse than abstinence-prone patients and controls. The implications of these preliminary findings for relapse prediction and typological development are discussed.

Reaction time during cocaine versus alcohol withdrawal: longitudinal measures of visual and auditory suppression

Visual and auditory stimulus discrimination tasks, analogous to those used in the Reitan-Klove Sensory Perceptual Examination, were performed by 12 cocaine-dependent and 5 alcohol-dependent patients after 1 week, 3 weeks, and 3 months of verified abstinence. Sixteen control subjects, who were not substance-dependent, performed the same tasks after comparable intervals. During each task, either visual or auditory stimuli were presented in the left, in the right, or in both sensory fields. A simple key press was made to discriminate these conditions. Cocaine-dependent patients responded more slowly than control subjects during both tasks. The reaction-time slowing persisted across all three sessions, spanning a 3-month period of abstinence. There were no significant differences between the cocaine-dependent and control groups in response accuracy. In the context of other findings, these findings are interpreted as reflecting an enduring effect of prior cocaine dependence on motor as opposed to sensory functioning.

The role of antisocial, affective, and childhood behavioral characteristics in alcoholics' neuropsychological performance

Chronic alcoholics demonstrate cognitive deficits when compared with nonalcoholics. These deficits are typically attributed to the direct effects of ethanol and its metabolites on the central nervous system (CNS). There are other factors, however, that differentiate alcoholics from controls, such as personality or behavioral characteristics. These factors may affect neuropsychological performance and thus alter the interpretation of alcoholic cognitive deficits as resulting solely from alcohol's toxic effects. To investigate this question, male and female alcoholics and peer nonalcoholic controls were compared on personality, behavioral, and cognitive measures. Alcoholics had greater numbers of antisocial behaviors, childhood behavioral disorder symptoms (CBD), and affective symptomatology, and had poorer neuropsychological performance than controls. The three personality and behavioral factors were positively intercorrelated with each other, and were negatively related to cognitive performance. The CBD factor proved to be the most consistent predictor of neuropsychological performance for both alcoholics and controls, and males and females. While the behavioral factors differentiated alcoholics from controls and predicted performance, significant differences between the groups in cognitive performance still remained when these factors were taken into account.

Alcohol, head injury, and neuropsychological function

Evidence is reviewed indicating that the extent of alcohol abuse alone cannot account for the neuropsychological deficits observed in alcoholics, and that alcohol abuse and head injury may interact in some patients to influence neuropsychological status. Alcohol abuse both increases the risk for head trauma and potentiates the resulting brain injury, which can lead to negative neuropsychological consequences. Clinicians involved in the treatment of addiction should assess patients for history of head injury, and neuropsychological deficits consequent to both head injury and ethanol. These deficits may limit patient ability to comply with addiction rehabilitation programs. Conversely, clinicians in acute care and rehabilitation of the sequelae of head trauma should routinely assess their patients for substance abuse, because such abuse can have a significant impact on recovery from brain injury.

Cognitive impairment among alcoholics: impact on drink refusal skill acquisition and treatment outcome

The impact of neuropsychological impairment on drink refusal skill acquisition and treatment outcome was examined in 33 male alcoholic inpatients. Subjects stratified by Abstraction scores on the Shipley Institute of Living Scale (SILS) performed differentially on drink refusal components of the Situational Competency Test (SCT) following a skills-based drink refusal intervention. Higher abstraction subjects tended to respond more rapidly on the SCT at post-training, had significantly higher scores on a quiz about effective drink refusal at baseline, and tended to improve more on the quiz following training than subjects with lower conceptual functioning. Aftercare attendance was significantly greater among the higher neuropsychological functioning group. When subjects were categorized by Brain Age Quotient no differences were found in skill acquisition nor in aftercare attendance. Subjects who showed the most learning on the California Verbal Learning Test demonstrated significantly better performance on the drink refusal quiz at post-training. Implications for alcoholism treatment are discussed.

Does neuropsychological test performance predict resumption of drinking in posttreatment alcoholics?

The prediction of resumption of drinking in posttreatment alcoholics was investigated as a function of five possible confounding variables: depression, anxiety, childhood symptoms of attention deficit and conduct disorders and family history of alcoholism. Male and female detoxified alcoholics (n = 103) in inpatient treatment programs were administered a neuropsychological battery and retested as outpatients 14 months later; peer nonalcoholics (n = 73), given the same battery, had a similar interest interval. Alcoholics who resumed drinking (N = 41) performed significantly poorer on an overall neuropsychological performance index than abstainers (N = 62) who performed significantly poorer than nonalcoholics. Stepwise multiple regression equations using the variables noted above revealed that depressive symptoms, ADD and the performance index were the only variables to enter the prediction (R2 = .26, p less than .001); depression accounted for most of the variance. At retest all three groups improved significantly, but not differentially, and were as significantly different at retest as at initial testing. Implications of these results are discussed.

Predictors of alcoholics' acquisition of treatment-related knowledge

Only modest relationships have been found between cognitive functioning and treatment outcome; there is some indication of better prediction of within-treatment progress. The current study attempted to determine whether either cognitive or sociodemographic/alcohol-related variables were predictive of learning in educational treatment. Eighty-seven male alcoholics were exposed to one hour of instruction on the medical effects of alcohol. Sociodemographic, alcohol-related, and cognitive functioning measures were obtained at the outset of treatment. Knowledge was assessed 24 hours prior to and 24 hours and three weeks after the intervention. Statistically significant increases in knowledge were found both 24 hours and three weeks following the educational intervention; retention of information declined significantly from 24 hours to three weeks post-intervention. Discriminant function analyses using either seven cognitive variables or six alcohol-related/sociodemographic variables significantly discriminated between learners and nonlearners 24 hours after the intervention. The weighted composite of measures in each of the analyses was able to successfully differentiate learners from nonlearners in over 70% of the cases. The findings suggest that the clinician may be able to employ a limited number of variables to differentiate between patients who will and will not be able to acquire knowledge from educational interventions.