Assessment of cognitive functions in patients with alcohol dependence disorder and its implications for primary care: A cross-sectional study

ABSTRACT

Introduction:

Alcohol dependence disorder (ADD) significantly impacts public health, society, and the economy. It is characterized by chronic alcohol use, withdrawal symptoms, and cognitive impairments, particularly involving frontal lobe dysfunction. The cognitive impairments, often underexplored, are particularly relevant in primary care settings, where early detection and intervention can greatly influence outcomes. This study investigates the cognitive effects of ADD using neurocognitive tests in inpatients at a government hospital in Central India, highlighting implications for family medicine and primary care management.

Materials and Methods:

This cross-sectional study assessed cognitive dysfunction and its link to alcohol dependence severity in 90 inpatients at a tertiary care hospital in Central India. Participants, aged 18–65 and meeting ICD-10 criteria for alcohol dependence, underwent cognitive evaluations using the Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), and Severity of Alcohol Dependence Questionnaire (SAD-Q).

Results and Discussion:

Patients with severe dependence exhibited significantly lower MoCA and FAB scores, with 72.2% scoring below the MoCA cutoff and 33.3% below the FAB cutoff. Negative correlations between SAD-Q and MoCA (–0.509) and FAB (–0.324) scores indicated that higher dependence severity was associated with greater cognitive decline. These findings highlight the importance of integrating cognitive assessments and rehabilitation into primary care practices for effective management of alcohol-related impairments.

Conclusion:

The study confirms severe cognitive impairments in ADD, particularly frontal executive functions. Routine cognitive evaluations in primary care settings can enable early detection and comprehensive management, improving patient outcomes and reducing the healthcare burden associated with ADD.

Introduction

Alcohol dependence disorder (ADD) represents a pervasive and multifaceted problem with significant public health, social, and economic implications. It is marked by a chronic pattern of alcohol consumption, often accompanied by withdrawal symptoms and a loss of control over drinking, leading to a wide array of physical, psychological, and social problems.[1] A WHO global status report based on 2019 data shows that an estimated 400 million people, or 7% of the world’s population aged 15 years and older, lived with alcohol use disorders globally. Of these, 209 million people (3.7% of the adult world population) lived with alcohol dependence.[2] Worldwide, 2.6 million deaths (nearly 5% of all deaths) were attributable to alcohol consumption in 2019. The alcohol-attributable mortality was heaviest among men, accounting for two million deaths compared to 600,000 deaths among women in 2019.[3] Deaths due to alcohol consumption exceeded those caused by diseases like tuberculosis, HIV/AIDS, diabetes, and other non-communicable diseases.

While the somatic and psychological consequences of alcoholism have been widely studied, the cognitive aspects have received less attention but are equally significant. Cognitive deficits associated with alcohol dependence encompass a wide spectrum, ranging from impairments in executive functions, memory, attention, and decision-making abilities to deficits in emotional processing, impulse control, and problem-solving skills.[4,5] These deficits have profound implications, as they perpetuate the disorder and hinder recovery efforts.

Previous research examining cognitive profiles in alcohol-dependent individuals highlights three primary theories:

1. Visuospatial Cognitive Impairment and Hemisphere Susceptibility: The visuospatial cognitive functions, primarily associated with the nondominant hemisphere, undergo widespread impairment and exhibit poor recovery post-alcohol withdrawal.[6,7]

2. Frontal Lobe Involvement and Executive Function Dominance: Frontal lobe structures are significantly implicated in the cognitive deficits of alcohol dependence, primarily through impairments in executive functions.[8,9]

3. Comprehensive Brain Damage Theory: Neuroanatomical and neuropsychological data suggest a broader explanation, with neuropsychological impairments affecting various cognitive functions in both verbal and visual domains, not limited to the right hemisphere and frontal lobes, supporting the hypothesis of global brain damage.[5,10]

Chronic alcohol consumption not only impacts physical health but also impairs cognitive functions, particularly those governed by the frontal lobe, posing a significant challenge to family medicine and primary care. These deficits hinder patients’ ability to engage in daily activities, make informed decisions, and adhere to treatment plans, thereby increasing the burden on primary care providers. Assessing cognitive functions in patients with ADD is essential for early identification and management of impairments. This study was conducted to determine how alcohol affects cognition in patients with alcohol dependence, the extent of its impact, and the specific cognitive domains affected by applying a battery of neurocognitive tests to inpatients at a government hospital in Central India. The findings aim to provide insights into comprehensive care in a primary care setting.

Materials and Methods

This cross-sectional study was aimed to measure and study the patterns of cognitive dysfunction in patients of alcohol dependence disorder and study the association between cognition and severity of dependence in patients of alcohol dependence. After obtaining permission from the Institutional Review Board, the patients for the study were selected using a purposive sampling technique from those admitted to the psychiatry department of a tertiary care hospital in Central India between the months of October 2023 and March 2024. Informed consent was obtained in the language of their comfort, either Hindi or English, after explaining the purpose of the study in detail. Hypothesized percentage of cognitive deficits in patients with substance use disorder is 31%.[11] Sample size was calculated using the formula: (n) = {Z² × P × (1 – P)}/D², with absolute precision (D) = 10% = 0.1. Based on the above formula, the sample size came out to be 83. Ninety subjects were included in the study, which was more than the sample size used in similar studies in the past.[12,13,14] Patients aged 18–65 years fulfilling criteria of dependence syndrome (F10.2) as per ICD-10 were included, after taking informed consent and who had reliable informant. Patients with pre-existing intellectual disability/head injury/organic brain syndromes/or any other medical comorbidities were excluded. Also, those who had dependence/harmful use of other substances except tobacco were also excluded. Patients with significant neurological dysfunctions (including sensory, motor, cranial nerve impairments, or abnormal reflexes) were excluded from the study.

In addition to a semi-structured questionnaire containing socio-demographic details related to the use of the substance, the following tools were applied: Montreal Cognitive Assessment (MoCA),[15] Frontal Assessment Battery (FAB),[16] Severity of Alcohol Dependence Questionnaire (SAD-Q),[17] Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar).[18]

Data was coded and recorded in the MS Excel spreadsheet program and was used for data analysis. Descriptive statistics were elaborated in the form of means/standard deviations and medians/interquartile ranges for continuous variables, and frequencies and percentages for categorical variables. Group comparisons for continuously distributed data were made using the independent sample “t” test when comparing two groups. Linear correlation between two continuous variables was explored using Pearson’s correlation. Statistical significance was kept at P < 0.05.

A diagrammatic representation of the methodology is shown in Figure 1.

Figure 1.

Diagrammatic representation of methodology

Results

Table 1 shows that in this study, the majority of participants (71.1%) came from urban areas, while the remaining 28.9% were from rural regions. Furthermore, most participants (71%) were married, 16% were separated, over 80% identified as Hindu, and nearly 85% were classified as upper class according to the 2024 update of the B. G. Prasad socio-economic scale.[19]

Table 1.

Socio-demographic parameters

Parameter	n	%
Age group (years)
22–36	30	33.3
37–51	54	60
52–66	6	6.6
Locality
Rural	25	27.8
Urban	65	72.2
Marital status
Married	70	77.8
Unmarried	6	6.6
Separated	14	15.5
Occupation
Unemployed	10	11.1
Unskilled worker	26	28.9
Semi-skilled worker	41	45.5
Skilled worker	11	12.2
Others	2	2.2
Social class (monthly per capita income in ₹)
Upper class (>9098)	76	84.4
Upper middle class (4549–9098)	11	12.2
Middle class (2729–4548)	3	3.3
Lower middle class (1364–2728)	0	0
Lower class (<1364)	0	0

In Table 2, it is seen that the majority of individuals (57.8%) initiated alcohol use between the ages of 20 and 24. Country liquor was the most commonly consumed type of alcohol (83.3%), followed by Indian-made foreign liquor (17.7%) and raw liquor (12.2%). Regarding the duration of alcohol use, 36.7% had been consuming alcohol for more than 10 years, while 33.3% had a history of 5–10 years. Daily consumption in terms of standard drinks (1 standard drink = 10 g pure alcohol) revealed that maximum (51.1%) consumed 10–20 drinks per day with a mean of 15.67 ± 6.96 standard drinks consumption. (Different types of liquor, e.g. country liquor, Indian-made foreign liquor, and raw liquor, were converted into standard drinks based on their alcohol content.)

Table 2.

Clinical parameters

Parameter	n	%
Age of initiation
16–20	12	13.3
20–24	52	57.8
24–28	26	28.9
Type of alcohol
Country liquor (w/r)	75	83.3
Indian made foreign liquor	16	17.7
Raw liquor	11	12.2
Total duration of alcohol intake
≤1 year	11	12.2
1–5 years	16	17.8
5–10 years	30	33.3
>10 years	33	36.7
Average consumption per day (standard drinks) (1 standard drink=10 g pure alcohol)
0–10	19	21.1
10–20	46	51.1
20–30	25	27.8
Immediate effect of taking alcohol
Euphoria	89	98.8
Relaxation	88	97.7
Forgetting things	27	30
Sleep	32	35
Physical withdrawal symptoms
Tremors	79	87.7
Sweating	56	62.2
Nausea/vomiting	59	65.5
Anxiety	50	55.5
Sleep disturbances	53	58.8
Headache	53	58.8
Psychological withdrawal symptoms
Craving	90	100
Restlessness	75	83.3
Inattention and poor concentration	82	91.1
Dysphoria	68	75.5
Physical complications
Seizures	11	12.2
Abdominal pain	21	23.3
Hallucinations	16	17.7
Psychological complications
Shame	17	18.9
Guilt	87	96.6
Social rejection	10	11.1
Low self-esteem	22	24.4
Tried abstinence
Yes	47	52.2
No	43	47.8
Reason for relapse
Craving	68	75.5
Peer pressure	59	65.5
Financial burden	23	25.5
Stress	22	24.4

The immediate effects of alcohol, such as euphoria (98.9%) and relaxation (97.77%), were frequently mentioned. Serious complications of alcohol withdrawal, including seizures (11 patients) and hallucinations (16 patients) were also observed. This study also examined reasons for relapse, identifying cravings (75.5%) and peer pressure (65.5%) as the most common triggers.

On assessing the various variables in Table 3, the mean score of MoCA came out to be 21.1556 ± 2.08209, and the mean score of FAB was 15.0111 ± 1.67, while the mean score of SAD-Q was 38.12 ± 8.22.

Table 3.

Mean values of clinical scales used

Variables	Mean	Std deviation
MOCA	21.15	±2.08
FAB	15.01	±1.67
SAD-Q	38.12	±8.22

The Pearson correlation coefficient between SADQ and MOCA and FAB was –0.509 and –0.324, respectively, as seen in Table 4, with a P value < 0.05, showing a significant inverse relationship between the severity of dependence and cognitive functions.

Table 4.

Correlation between severity of dependence and cognitive functions

	MOCA	FAB
SAD-Q
Pearson correlation	–0.509**	–0.324**
Sig. (two-tailed)	0.000	0.002
n	90	90

It was found that the t value between MoCA and FAB scores with the severity of dependence was 4.409 and 3.411, respectively, with a P value < 0.05 in both cases [Table 5]. Therefore, it can be inferred that as the severity of dependence increased from moderate to severe, the scores in cognitive tests decreased.

Table 5.

Test of significance

Measure	Severity (based on SAD-Q)	n	Mean	±SD	t*	P**
MoCA scores	Moderate	25	26.36	±1.35	4.409	0.000
	Severe	65	24.69	±2.13
FAB scores	Moderate	25	15.72	±0.89	3.411	0.001
	Severe	65	14.74	±1.82

*Equal variances not assumed, **significance P<0.05

Discussion

There have been several studies in recent years assessing cognitive status in patients with various substance use disorders, be it harmful use or dependence, at different stages of their treatment (active consumer, recently detoxified, or abstinent). However, there has been a dearth of literature in Central India on the assessment of neurocognitive functions in alcohol-dependent patients. This study aimed to bridge this gap by assessing cognitive functions in patients with alcohol dependence using the FAB and MoCA while minimizing confounding by excluding other substance users (except tobacco).

Cognition encompasses mental processes such as attention, memory, executive functions, language, visuospatial skills, processing speed, reasoning, problem-solving, social cognition, and orientation. These functions enable individuals to acquire, process, store, and utilize information effectively. Alcohol dependence, a chronic condition, disrupts various cognitive functions. Even mild to moderate alcohol consumption can negatively impact cognitive abilities, affecting tasks that involve acquiring, storing, retrieving, and using information.[20] The severity of dependence is a key factor in deciding deaddiction treatment, with more severe cases often needing intensive care and facing greater difficulty in quitting. In family medicine and primary care, assessing severity early helps guide timely interventions and referrals, improving outcomes and reducing the burden on specialized services.

The study had a majority of the sample (71.1%) from an urban background, while the remaining 28.9% were from rural areas [Table 1]. This distribution is expected in view of the geographic location of the study site and the social strata of the study sample. Urban dwellers often have greater awareness and cultural consciousness regarding the adverse effects of substance use, whereas rural inhabitants may have a higher cultural acceptance of alcohol use. Additionally, most participants (71%) were married, 16% were separated, over 80% were Hindu, and nearly 85% belonged to the upper class as per the B.G. Prasad socio-economic scale updated for the year 2024.[19]

The study uncovered important insights into the initiation, consumption patterns, withdrawal symptoms, and complications related to alcohol use. The initiation age of alcohol use among participants predominantly fell between 24 and 28 years (57.8%) [Table 2]. This trend underscores the critical period during young adulthood when individuals are particularly vulnerable to developing alcohol dependence, consistent with findings from Grant et al.[21] that early initiation of alcohol use is a significant predictor of future dependence.

Serious complications of alcohol withdrawal, such as seizures (11 patients) and hallucinations (16 patients), were observed [Table 2], indicating the potential for severe cognitive and physiological disruptions in patients with alcohol dependence, echoing Victor and Adams[22] documentation of neurological impairments associated with chronic alcoholism. It can be deduced that mainly the feeling of euphoria and relaxation could give reinforcement to the individuals, by acting on the reward pathway in the Nucleus Accumbens, which propels them toward seeking alcohol. But later on, after developing tolerance, as the intake of alcohol increases, maximum patients developed physical withdrawal symptoms in the form of tremors and gastric disturbances such as nausea and vomiting, before developing serious complications such as seizures, cirrhosis, or hepatic encephalopathy.

The study further explored the reasons for relapse, with cravings (75.5%) and peer pressure (65.5%) being the most prevalent factors [Table 2]. The high rate of relapse emphasizes the need for targeted interventions to address these triggers, supported by Witkiewitz and Marlatt’s[23] model of relapse prevention.

Mild-to-severe neurocognitive impairment affects 50%–80% of people with alcohol use disorders, mostly impairing executive processes, episodic memory, and visuospatial skills due to numerous brain injuries.[20,22] Executive functions, which include planning, decision-making, problem-solving, and inhibitory control, are primarily mediated by the frontal lobes. This study reveals a significant difference in cognitive functions between patients with moderate and severe alcohol dependence. Patients with severe dependence scored significantly lower on both the MoCA and the FAB compared to those with moderate dependence [Table 3].

Specifically, the MoCA scores ranged between 18 and 29, with a majority of the sample (72.2%) scoring below the cut-off score of 26, indicating cognitive impairment [Table 3]. The mean MoCA score was 21.1556 (SD ± 2.082). In MoCA, there are six domains: Memory; Executive Functioning; Attention; Language; Visuospatial; and Orientation. Out of these, it is seen that attention, memory, executive functions, and, in severe cases, orientation are the major domains, which are likely to get affected in patients with alcohol dependence.[24,25,26] These cognitive functions play a significant role in routine activities such as decision-making, interpersonal relationships, and managing finances and employment.

On applying the FAB, the alcoholic group had a mean score of 15.0111 (SD ± 1.672) [Table 3]. In the absence of universally established categories for interpreting FAB scores, an arbitrary cutoff score of 15 was adopted to categorize the study population. This approach aligns with certain studies that have utilized similar thresholds in specific contexts.[27] In the study sample, the FAB scores ranged between 10 and 18, with 33.3% of participants scoring below the cut-off score of 15, indicating frontal lobe dysfunction. Long-term alcohol intake leads to substantial deficits in conceptualizing, programming, inhibitory control, and general executive function. Longer periods of alcohol intake and dependency were linked to impaired executive functioning. The day-to-day functioning and daily living activities are hampered significantly. The findings of this study back up earlier research that has shown that alcohol has a negative impact on executive functioning.[28] In a study done in Eastern India, 38% of individuals with alcoholism, different executive functions such as abstract thinking, motor programming, and cognitive flexibility were compromised after assessment on the FAB.[29] The FAB’s total score was lower in the substance-abusing group than in the control group in the study.

The study revealed a significant correlation between the severity of dependence, assessed using the SAD-Q, and cognitive functions [Table 4]. It was found that 77% of the subjects had severe dependence, and severe dependence is also associated with increased memory impairments. The correlation coefficient between MoCA and SAD-Q was –0.509 (Sig. two-tailed = 0.000 < 0.050), indicating a moderate negative correlation between the severity of alcohol dependence and cognitive function. This adds weight to the hypothesis that as the severity of alcohol dependence increases, cognitive functions tend to decrease, most likely because of the neurotoxic effects of alcohol in the form of extensive involvement of the frontal lobe and associated structures.[8,9,30]

The correlation coefficient between FAB and SAD-Q is –0.324 (Sig. two-tailed P value = 0.002), indicating a weak to moderate negative correlation between the severity of alcohol dependence and executive function as measured by FAB [Table 4]. This implies that higher alcohol dependence is associated with lower executive function performance. This finding aligns with previous research, such as Ratti et al.,[31] which reported significant deficits in attention, memory, and executive functions in individuals with severe alcohol dependence compared to those with moderate or mild dependence. Similarly, other studies have demonstrated an inverse relationship between alcohol dependence severity and cognitive task performance, particularly in memory and executive functions.[32,33] A possible explanation for this association is that chronic alcohol use leads to neurotoxic effects, particularly in the prefrontal cortex, resulting in impaired executive functioning, decision-making, and cognitive flexibility.

Despite the study’s comprehensive findings, certain limitations need to be addressed. The research was restricted to adult males from a tertiary care hospital in Madhya Pradesh, with most participants belonging to urban areas, Hindu backgrounds, and higher socio-economic status. This limits the generalizability of the results to rural populations and individuals from diverse religious and cultural backgrounds. Additionally, nutritional status and vitamin levels were not considered, which could serve as potential confounders. The study relied on self-reported data for alcohol consumption patterns, withdrawal symptoms, and motivational factors, making it susceptible to recall and social desirability biases. While MoCA and FAB are widely used cognitive screening tools, they may not fully capture subtle cognitive impairments specific to alcohol dependence. Incorporating executive function-specific assessments, such as the Wisconsin Card Sorting Test or Stroop Test, could have provided a more detailed evaluation. Furthermore, the study presents mean values for clinical scales (FAB, MoCA, and SADQ), but a subdomain-level analysis was not performed. Future research should explore subdomain scores to offer a more granular understanding of cognitive impairments. Additionally, key confounding factors such as age, duration of alcohol use, withdrawal state, and benzodiazepine use were not controlled for in the analysis. Future studies should employ multivariate statistical approaches to better isolate the effects of alcohol dependence severity on cognition. Expanding research to include a broader demographic and geographic representation, along with comprehensive neuropsychological assessments and advanced statistical models, will enhance the understanding of cognitive deficits in alcohol dependence.

Conclusion

This study underscores the crucial role of family medicine and primary care in identifying and managing cognitive impairments in patients with ADD. Deficits in memory, attention, and executive functioning can significantly hinder a patient’s ability to engage with treatment programs such as cognitive-behavioral therapy. As the first point of contact, primary care providers are uniquely positioned to conduct early screenings and initiate timely interventions. Routine neurocognitive assessments in these settings can guide more personalized prevention, treatment, and rehabilitation strategies. Furthermore, family physicians offer holistic care by addressing the psychosocial and familial aspects of alcohol dependence, thereby promoting long-term recovery and enhancing the patient’s quality of life. Integrating cognitive health into primary care is essential for effective, comprehensive management of ADD.

Author contributions

KS: Conceptualization and design (Lead role in developing project concept, overall design, and objectives), Definition of intellectual content (Primary responsibility for defining the main intellectual framework), Investigation (Lead responsibility in conducting primary research and investigations), Manuscript writing (Major role in writing the manuscript, structuring the document). VN: Conceptualization and design (Support role in refining and improving design), Definition of intellectual content (Assist in reviewing and ensuring alignment with objectives), Investigation (Assist with data collection and preliminary analysis), Manuscript writing (Contribute to drafting sections of the manuscript). RM: Conceptualization and design (Support role in providing feedback), Definition of intellectual content (Provide suggestions for content development), Investigation (Support role in organizing data), Manuscript writing (Provide review and suggestions for improvement). SP: Conceptualization and design (Lead role in shaping overall project concept, integrating ideas), Definition of intellectual content (Final review and enhancement of intellectual content), Investigation (Oversee the integrity and depth of investigation, validate findings), Manuscript writing (Finalize and refine manuscript, contribute to the writing of complex sections).

Key message

Alcohol dependence disorder is linked to significant cognitive impairments, especially in frontal lobe functions. Routine cognitive assessments in primary care can aid early detection and improve management, reducing the overall healthcare burden.

Data Availability statement

The data set used in the current study is available.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.