Cognitive Function of Alcohol Abuse Patients May Influence Treatment Outcome
DURHAM, N.C. -- Clinicians treating newly recovering alcohol abuse patients should assess the patients' "executive" cognitive functioning prior to the start of treatment and adjust treatment protocols in accordance with those capabilities, according to researchers at Duke University Medical Center. Otherwise, they said, patients may not get the most out of treatment early in the treatment process.
In a study reported in the September 2004 issue of Alcoholism: Clinical & Experimental Research, the scientists found that alcohol abuse patients showed significant deficits in their executive functioning during the critical first weeks of abstinence.
According to the researchers, the early phases of most treatment programs for alcohol abusers commonly require working in groups, making plans for the future, inhibiting behaviors related to their addiction, and remembering specific things. These actions demand individual skills that are part of what experts call "executive functioning" – including abstract thinking, cognitive flexibility and persistence. However, such executive functioning can be impaired for weeks after a person quits drinking, the researchers said.
"The term 'executive functioning' is very much a business analogy," said H. Scott Swartzwelder, Ph.D., senior author on the study. Swartzwelder is a professor of psychiatry at Duke and a senior research career scientist at the Durham Veterans Affairs Medical Center (VAMC). "The executive of the business monitors various departments so that the company and employees can move forward in as efficient and effective a way possible. In terms of real-world activity, executive functioning has everything to do with who we are, how we organize our lives, how we plan and then execute those plans."
The frontal cortex region of the brain, which is responsible for this type of functioning, is known to be highly susceptible to damage from alcohol, said Swartzwelder. Thus, he said, chronic alcohol abuse can seriously impair a person's executive functioning during the period of abuse and can continue for some time after the person quits drinking. At present it is not clear how long deficits in executive functioning may last, he said.
"Alcohol effects executive functioning both acutely and chronically," said Swartzwelder. "It occurred to us that, among people who have just stopped drinking, there may still be some residual effects from their acute consumption, as well as cumulative effects from their chronic drinking.
"These deficits may very well limit a person's ability to engage in effective planning and strategizing, both in terms of their treatment compliance and in terms of their everyday lives. This implies that, not only do the clinicians who are treating alcoholics have to take their executive dysfunction into account, but so do their spouses, children, bosses and other social contacts."
The participants recruited for the study were all male veterans receiving treatment at the Durham VAMC. In their study, the researchers administered memory and executive-function tests to two groups. The first group -- comprising 27 patients classified as alcohol-dependent -- received treatment at an outpatient substance abuse treatment program affiliated with the VAMC. Eighteen non-alcohol dependent patients served as an aged-matched "control" group and received care at the primary care clinic at the VAMC. To be eligible for participation, patients must have been off alcohol for six weeks or less. Patients with a history of frequent opiate or inhalant use, schizophrenia or active psychosis were deemed ineligible for participation.
After initial interviews about the patients' background and daily functioning, the researchers administered neuropsychological tests designed to show measures of fluency, abstract reasoning, cognitive flexibility and psychomotor speed.
The researchers found significantly lower cognitive performance in the recovering alcoholics versus the control group on several tests. Scores of non-verbal fluency, verbal and non-verbal reasoning, psychomotor speed and cognitive flexibility all suffered in the alcohol-dependent patients compared to the control group.
Additionally, patients with alcohol dependence had more difficulty distinguishing words they were asked to remember from semantically related words during retrieval. Their non-verbal memory was also poorer. However, the researchers noted that executive functions were not consistently impaired across the board.
"We're learning that it is important to evaluate what the patient brings to the table, so to speak, early in the treatment process," said Swartzwelder. "Clinicians should be made more fully aware of impairment in executive functioning at the start of treatment programs.
"Our findings are less about what a patient should be doing at the start of treatment and more about what a clinician might want to avoid having them do," he said. "Don't expect a recovering alcoholic to be able to learn and remember very well shortly after they've stopped drinking. Scale down clinical expectations related to memory, planning and use of abstract thinking skills because those aspects of treatment will be harder for the patients to deal with until their executive functioning gets back on track."
Swartzwelder and his team say that their next step is to explore how long it takes the majority of people to regain most of their executive functioning.
"We hope to eventually provide a 'toolbox' of techniques for clinicians in the interim that compensates for the adverse effects of executive dysfunction on treatment," said Sandra Zinn, Ph.D., a rehabilitation scientist with both Duke and the Durham VAMC and lead author on the study. Zinn is a career development awardee in Rehabilitation Research & Development through the Department of Veterans Affairs. She is currently working on techniques to help overcome executive dysfunction in various populations including those seeking treatment for alcoholism.
Roy Stein, M.D., also of Duke, is an author on the study.
The study was supported by the U.S. Department of Veterans Affairs, Veterans Affairs Administration, Health Services Funds, a Rehabilitation Research & Development Career Development award, a VA Merit Review grant, a VA Senior Research Career Scientist award and a grant from the National Institute of Alcohol Abuse and Alcoholism, part of the National Institutes of Health.