Recognising, assessing and responding to cognitive impairment in addiction treatment settings

On 25 November Dr Jamie Berry, Senior Clinical Neuropsychologist and Director at Advanced Neuropsychological Treatment Services (ANTS) in Sydney, delivered a one day workshop on using the Montreal Cognitive Assessment (MoCA) to assess and use to develop appropriate strategies to respond to cognitive impairment in people accessing addiction treatment. The workshop followed Dr Berry’s engaging and informative presentation to the Christchurch Addiction Leadership Day the day before. This presentation is available on the Matua Raki website.

Dr Berry is a Clinical Neuropsychologist with experience working across a range of settings including neuro-rehabilitation, mental health, dementia and substance use disorder treatment. He is co-author of a recent paper (see below) on the use of the MoCA to assess head injury and cognitive impairment within a residential treatment setting.

Recapping the information shared at Leadership Day Dr Berry set the scene for the workshop, reminding the participants from across New Zealand about why cognitive impairment is a major issue within addiction treatment settings. The prevalence of traumatic brain injuries in people who access addiction services is high and many people have a history of multiple injuries with consequent, often significant, cognitive impairment. Dr Berry outlined the results of the recent study (see below) in a therapeutic community setting in Sydney. Of the people in treatment over the period of the study almost 50% of the people in treatment at that time had evidence of cognitive impairment that would meet the criteria for early dementia if the person was over 65 years old. The presence of cognitive impairment at this level indicates an under recognised barrier to treatment engagement and effectiveness as people with cognitive impairment are more likely to struggle in treatment and to drop out prematurely. Recognising and responding to the impact of cognitive impairment will improve both treatment engagement and wellbeing outcomes.

When working as a practitioner in a community setting it was his experience that it was ‘normal’ that the people he was seeing had had at least one if not more episodes where they had a head injury and lost consciousness either due to a motor vehicle accident (MVA), rugby injury or assault. In the study over 60% of people had been knocked unconscious at least four times. The impact of traumatic brain injury (TBI) on people, especially frontal lobe injuries, are that they are more likely to be impulsive, process information slower and find it more difficult to learn new information. These are all issues that can and will impact on people’s ability to engage with and benefit from interventions. When the additive effects of substance use, alcohol in particular, are factored into the equation it is clear that addiction practitioners should expect people they see to have some form of cognitive impairment that may or may not resolve if they abstain from substances. Dr Berry recommended the routine use of a simple screening question for all people accessing treatment services to ascertain if they have had a possibility of having a TBI:

"Have you ever lost consciousness following a blow to the head?” 

 

Dr Berry then introduced participants to the use and interpretation of the MoCA with people accessing addiction services. The MoCA is a validated tool to screen for the presence of cognitive impairment that does not require the time, the training or specific neuropsychological skills to use and interpret. While the MoCA results are indicative of cognitive impairment and probable damage in a range of brain locations, and thus functioning, results are not specific or detailed enough to generate diagnostic information and as such it does not replace a full neuropsychological assessment. However with limited access to neuropsychologists in most areas of New Zealand the use of the MoCA fills an important function when completing a comprehensive assessment and developing appropriate treatment and intervention planning with people accessing addiction services.

Initially developed as a tool to screen for dementia, and specifically Alzheimer’s Disease, the MoCA has emerged as being particularly useful when screening for damage to the frontal lobes of the brain. Frontal lobe damage is often a consequence of traumatic brain injuries, particularly MVAs, but can also be a consequence of the effects of protracted substance use and withdrawal. Dr Berry stated that the MoCA is a more useful tool to use within the addiction sector than the more widely known Mini Mental State exam as this does not screen for frontal lobe damage and impairment. As Dr Berry worked through the items of the MoCA he identified the specific relevance of each item, e.g. executive functioning, and what responses to the item indicate in terms of both ‘normal’ and impaired functioning. When results to items are interpreted with this knowledge then specific adaptations to treatment and intervention plans can be made to address areas of cognitive impairment, e.g. use of diaries to compensate for short term memory loss. Dr Berry was clear that simply using the MoCA as a tick box exercise without knowing how to use the results to inform treatment and intervention planning was a pointless exercise. 

Using the information gained from the MoCA is useful to identify transient and long term cognitive impairment, especially when used repeatedly during a period of treatment such as might occur during withdrawal management and/or a period of residential treatment. If cognitive impairment does not improve over time with abstinence then it is likely that the person has more long term damage that needs to be taken into account in terms of immediate treatment and long term rehabilitation. Dr Berry has developed a programme of ‘cognitive remediation’ specifically to address frontal lobe impairment as identified by responses to the MoCA. This programme combines strategies that help a person learn to manage the consequences of impairment, such as reducing distractions if a person has attention problems, and cognitive remediation. Cognitive remediation involves the use of focused activities that aim to address specific cognitive deficits, utilising and encouraging neuroplasticity. Examples of some of these activities are available online on the Lumosity website - lumosity.com, and these activities can be used to improve cognitive functioning through the regular practice of activities that are targeted to areas of reduced or impaired functioning.

Overall participants found that the workshop was very relevant and practical and that Dr Berry presented complex information in a clear and informative manner. Participants also felt confident to use and interpret the MoCA in the future practice.

Marceau, E. M., Lunn, J., Berry, J., Kelly, P. J. & Solowij, N. (2016). The Montreal Cognitive Assessment (MoCA) is sensitive to head injury and cognitive impairment in a residential alcohol and other drug therapeutic community. Journal of Substance Abuse Treatment, 66 30-36.