|Ahead of print publication
Cognitive deficits in alcohol dependence—A case–control analytical study
Pooja Vijay, Aslam Khan, AV Sowmya, Suprakash Chaudhury, Bhushan Chaudhari, Daniel Saldanha
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Submission||26-Nov-2021|
|Date of Decision||07-Feb-2022|
|Date of Acceptance||09-Mar-2022|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Use and abuse of alcohol is well known. Its abuse, predominantly its dependence, can cause medical, psychological, and social issues. Excessive alcohol intake over time is linked to cognitive problems, including memory loss. Excessive alcohol use has been linked to significant cognitive deficits that can last even after the person stops drinking. Executive functioning impairments are most likely to impact rehabilitation outcomes in people with cognitive impairment. Aim: To study the cognitive impairments in alcohol dependence and comparing with healthy individuals. Methods: An observational, analytical case–control study was done on 30 alcohol-dependent patients after stabilization and 25 healthy individuals from July 2019 to July 2021 in a tertiary care center in Pune; all subjects after diagnosis were assessed with Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), Barratt Impulsiveness Scale, Stroop Test, and the Wisconsin card sorting test (WCST). Results: The mean score on MMSE of the case group was 28.60 and the controls—29.72. The mean score on FAB of the case group was 16.45 and the controls—17.4. The mean score on BIS of the case group was 16.45 and in control 17.4. Stroop Effect score of the case group was 187.16 seconds and in control it was 146.92 seconds, all being statically significant in comparison. On the WCST, all the findings were statistically significant. Conclusion: Long-term alcohol consumption affects executive functions considerably. The current study showed significant cognitive deficits in individuals with alcohol dependence mainly in executive functions, working memory, and high impulsiveness.
Keywords: Alcohol dependence, cognitive deficits, executive functions, healthy individuals
|How to cite this URL:|
Vijay P, Khan A, Sowmya A V, Chaudhury S, Chaudhari B, Saldanha D. Cognitive deficits in alcohol dependence—A case–control analytical study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=343495
| Introduction|| |
Alcohol consumption may be traced to 7000 BC in ancient China, based on archaeological evidence of humans producing and consuming alcoholic drinks. It has been suggested that humans evolved a taste for alcohol as a result of the adaptive benefit of consuming fruits that have been fermented throughout the last 40 million years of development. In India, the earliest record found was of the Dravidians and their art of toddy tapping.
Alcohol use disorder is a psychiatric illness marked by an inability to control alcohol consumption, which has serious psychological, physical, and social consequences. Alcohol is the second most abused drug in India. The excessive consumption of drugs has become a big problem in the country, affecting lakhs of children and youth. The prevalence of alcohol use disorder is 14.6% in India. The burden of alcohol dependence is more in the urban–non-metro areas, 5.6%.,
Alcohol dependence is a common disorder which leads to physical, psychological, and social problems. Chronic excessive alcohol consumption is associated with cognitive impairments manifesting memory impairments. Cognitive deficits hamper the initiation and sustaining of abstinence, obstruct good decision making, better social interactions, healthy interpersonal relationships, and behavioral dysfunction. Considerable evidence shows that excessive use of alcohol is associated with increased cognitive deficit that can persist after cessation of drinking. The executive functioning deficits among the cognitive impairment are most likely to affect rehabilitation success. These individuals also exhibit cognitive symptoms such as impulsivity, concentration, and memory issues, even if it is not expressly indicated in the diagnostic criteria.
The cognitive deficits in people suffering from Korsakoff syndrome, which is caused by Thiamine insufficiency, have been studied extensively. However, no large-scale epidemiologic studies have been conducted to determine the prevalence of cognitive impairment in abstinent alcoholics that is not visible during regular interviews. Cognition is the internal representation, maintenance, and updating of information for the purpose of exerting control over thoughts and behaviors. It may also refer to a subset of executive processes that steers a person's behavior toward or away from a certain activity. By creating goals and therefore restricting habitual behavior, it promotes adaptive decision-making. Addiction is both a cause and an outcome of a loss of cognitive control.
The dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC)/paracingulate cortex, parietal cortex, dorsal striatum, pre-supplementary motor area (preSMA), lateral orbitofrontal cortex (OFC), and thalamus are involved in cognitive regulation.,, Connections between the ventral striatum, amygdala, and hippocampus, as well as limbic and other motivational circuits, are essential for self-control in the presence of desire-inducing interoceptive or external stimuli., The patient's cognitive impairments make it difficult for them to continue their therapy, engage in treatment, and live their lives efficiently. Assessing these functions is critical because it allows us to select the most appropriate treatment and timing the treatment. Although there are extensive data available on the cognitive deficits in alcohol-dependent individuals, there are minimal data available comparing cognitive deficits with healthy individuals in India. With this study, we aim to fill these gaps which will lead to a deeper understanding of the situation and the treatment approach of patients with alcohol dependence.
| Materials and Methods|| |
This cross-sectional, observational, case–control study was carried out in the Department of Psychiatry of a Tertiary Care Hospital attached to a Medical College from August 2019 to September 2021. Institutional Ethics Committee clearance was obtained before start of study (vide IESC/180/2019 dated 11/09/2019). Written informed consent was obtained from every subject enrolled for the study.
Sample size calculation
Sample size was determined based on the prevalence of alcohol dependent syndrome in India, being, 2.7%. Using the Fisher's formula,
N = Minimum sample size for a statistically significant survey
Z = Normal deviant at the portion of 95%, confidence interval = 1.96
p = prevalence (2.7%)
d = margin of error acceptable or measure of precision = 0.05
Calculated value = 41
All male patients with alcohol dependence syndrome reporting to the tertiary care center.
Equal number of age, sex, and education-matched individuals.
- Patients in the age group of 18 to 60 years.
- Patients diagnosed with the ICD 10 (DCR) criteria for Alcohol dependence syndrome.
- Patients who are stabilized.
- Individuals aged 18 to 60 years.
- Patients with neurological illness, head injury, or loss of consciousness.
- Patients with active systemic illness or chronic illness.
- Patients on neuroleptics or other substance abuse (except nicotine).
- No history of any substance use, psychiatric, or medical illness.
- No family history of any substance use.
1. Socio-demographic and clinical proforma
A specially designed proforma was used to document background details, and a socio-demographic profile along with a specially designed proforma was used to document the alcohol history.
2. Mini–Mental State Examination (MMSE):
The MMSE, a 30-point questionnaire, is used to assess cognitive impairment in clinical and research contexts. It is also used to evaluate the level and development of cognitive impairment, as well as to track an individual's cognitive changes over time, making it a useful tool for documenting a patient's reaction to therapy. Registration, attention and calculation, recollection, language, capacity to follow basic commands, and orientation are all examined, and it was shown to have both good test–retest reliability (0.80–0.95) and acceptable sensitivity and specificity.
3. Frontal Assessment Battery (FAB):
The FAB is a brief battery of six neuropsychological tasks designed to assess frontal lobe function at bedside. The six FAB tasks explore cognitive and behavioral domains that are thought to be under the control of the frontal lobes, most notably conceptualization and abstract reasoning, lexical verbal fluency and mental flexibility, motor programming and executive control of action, self-regulation and resistance to interference, inhibitory control, and environmental autonomy. It has a Cronbach's coefficient alpha of 0.78 and discriminant validity of 89.1%.
4. Barratt's impulsiveness scale (BIS):
The BIS is a gold-standard measure that has had a significant impact on contemporary theories of impulse control and has been used extensively in research on impulsivity and its biological, psychological, and behavioral consequences. The BIS is a 30-item questionnaire that assesses trait impulsivity in three areas: attentional, motor, and non-planning with a Cronbach alpha coefficient of 0.77.
5. Stroop test:
The Stroop Test is a neuropsychological test that is widely used to measure the capacity to prevent cognitive interference, which happens when the processing of one sensory characteristic interferes with the simultaneous processing of another, a phenomenon known as the Stroop Effect. It is applied to measure other cognitive functions such as attention, processing speed, and cognitive flexibility.
6. Wisconsin Card Sorting test (WCST):
The WCST evaluates the cognitive flexibility and problem solving and is considered the golden standard of the executive function's evaluation with a >90% reliability. The task consists of combining two decks of cards (64 cards each) with four stimuli cards. The examinee is instructed to combine the cards and receives feedback from the examiner about the success or failure of each association.
Method of recruitment and procedure
The ICD 10 DCR criteria for diagnosis of Alcohol dependence were used to select the patients of alcohol dependence. The included patients were evaluated on socioeconomic demographic scale and MMSE. The alcohol-dependent patients were administered the WCST, the Stroop test, the BIS, and the FAB. These tests were administered once the patient was stable and fit for discharge. The psychological tests were scored and evaluated as per the test manuals. These scores were compiled on the Master chart on Microsoft excel.
Statistical analysis was performed using the SPSS (IBM, CHICAGO, USA). Frequency data were compared using Chi-square test and Fisher's Exact test, and ordinal data by Mann–Whitney test. Spearman's rho test for correlation and multiple linear regression were also applied.
| Results|| |
The mean age of the 30 cases was 42.56 years and that of the 25 controls was 42.00 years. The mean years of duration of alcohol intake was 16.72 years. The sociodemographic details are illustrated in [Table 1] and alcohol-related history in [Table 2]. The mean score on MMSE of case group was significantly lower than the controls, but all subjects scored higher than cut-off score. The mean score on FAB of the case group was significantly lower than the controls, but all subjects scored higher than the cut-off score. The mean score on BIS of the case group was significantly lower than the control subjects. The mean Stroop Effect score of the case group was significantly higher than the control subjects [Table 3]. On the WCST, all of the findings were impaired in the alcohol-dependent group and statically significant [Table 4]. In multiple linear regression analysis for predictors of Stroop effect, the multiple correlation coefficient ”R” value of 0.854 indicates a good level of prediction. The coefficient of determination (”R Square,” R2) value of 0.730 implies that our independent variables explain 73.0% of the variability of the Stroop effect [Table 5]. The F-ratio in the ANOVA table shows that the independent variables statistically significantly predict the dependent variable, F (3, 26) = 23.419, P <.000, i. e., the regression model is a good fit of the data [Table 6]. Unstandardized coefficients indicate how much the dependent variable varies with an independent variable when all other independent variables are held constant. Consider the effect of age in this example. The unstandardized coefficient, B1, for age is equal to 0.980. This means that for each 1-year increase in age, there is an increase in Stroop effect score of 0.980. One can test for the statistical significance of each of the independent variables. This tests whether the unstandardized (or standardized) coefficients are equal to 0 (zero) in the population. If P < .05, you can conclude that the coefficients are statistically significantly different to 0. You can see from the “Sig.” column that SPA, income, and age are statistically significantly different from 0 (zero) [Table 7]. To summarize the above results, a multiple regression was run to predict Stroop effect scores from Stroop Percentile score, income, and age. These variables statistically significantly predicted Stroop effect, F (3, 26) = 23.419, P <.000, R2 =0.730. All three variables added statistically significantly to the prediction, P <.05.
|Table 1: Demographic characteristics of alcohol-dependence patients and control subjects|
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|Table 2: Distribution of alcohol-dependence patients and control subjects according to duration of alcohol intake, quantity of alcohol intake, type of alcohol consumption, and last drink of alcohol intake|
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|Table 3: Scores of alcohol-dependence patients and control subjects on MMSE, frontal assessment battery (FAB), Barratt impulsiveness scale-11 (BIS-11), and Stroop test|
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|Table 4: Comparison of alcohol-dependence patients and control subjects on results of Wisconsin card sorting test|
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|Table 5: Multiple linear regression analysis for predictors of Stroop effect: Model summaryd|
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|Table 6: Multiple linear regression analysis for predictors of Stroop effect: ANOVAa|
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|Table 7: Multiple linear regression analysis for predictors of Stroop effect: Coefficientsa|
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| Discussion|| |
Alcohol abuse and dependence pose a major problem all over the world. Every year, 3.3 million people die because of hazardous alcohol use throughout the world, and alcohol use is responsible for 5.1% of the worldwide disease burden.
In India, the pattern of drinking has shifted from infrequent or ceremonial consumption to routine social consumption. The majority of modern alcoholics consumed alcohol on a weekly basis. In Pune, there appears to be a culture of excessive daily drinking among the lower and lower-middle classes, with working-class men congregating around liquor outlets every evening to drink and socialize.
The 30 alcohol-dependent patients and the 25 in the control group had a mean age of 42.56 and 42 years, respectively, thereby matching the cases and control group almost accurately. Most of the participants had completed their high school education. The majority of the cases belonged to rural set-up, whereas the controls belonged to an urban set-up.
The average years of consumption of alcohol was 16.72 years; surprisingly, all the patients in this study drank alcohol daily of an average of 261.25 ml/day and the country liquor majorly, 73.33%. The effects of consumption of alcohol are many, but the cognitive deficits are the least looked upon. When compared with control groups, abstinent alcoholic males score badly in mental speed, sustained attention, verbal working memory, logical memory, verbal memory, visuo-constructive ability, and executive functioning (planning, processing speed, and cognitive flexibility). According to the results of a research done in Northern Italy, 70.73% of the participants failed at least one of the neuropsychological test questions. These findings are consistent with research that indicated virtually all participants (93%) were clinically impaired in at least one of the five cognitive domains before to entering residential treatment, and that 71% were clinically impaired after 10 days. This implies that abstinence has a role in neuropsychological functioning, but it is not the only one, as some persons still have cognitive problems.
Frontal (executive) function deficits have been identified in long-term alcoholics, including domains of planning, abstraction, attention, shifting of attention, mental flexibility, and idea creation. On applying the Frontal assessment battery, the alcoholic group had a mean score of 16.25, which was statistically significantly lower than the controls who scored 17.4. 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 findings of this study back up earlier research that has shown that alcohol has a negative impact on executive functioning. The mean FAB score of the patients was 10.2 and the control was 16.96, which was statistically significant in our study. In a study done in Eastern India, 38% of individuals with alcoholism, different areas of executive function were compromised after assessment on the FAB. The FAB's total score was lower in the substance-abusing group than in the control group in a study. In three cognitive areas, they exhibited more deficits on average: abstract thinking, motor programming, and cognitive flexibility. In this study, the control group, no significant associations were found between drug use characteristics, FAB scores, and other conventional frontal neuropsychological tests.
MMSE on both the cases and the control group scores fell within the cut-off score of 24. The alcoholics scored 28.60 and the control scored 29.72, mean scores. Memory is a complex function that includes multiple components and processes, and in patients with AUD, it is associated with short- and long-term memory deficits., Mild-to-severe neurocognitive impairment affects 50% to 80% of people with alcohol use disorders, mostly impairing executive processes, episodic memory, and visuospatial skills due to numerous brain injuries. In an Indian research conducted in Himachal Pradesh, individuals with alcoholism scored 25.45 on the MMSE, whereas the normal control group scored 27.23. The mean MMSE ratings of the two groups differed statistically significantly (P = 0.010). In a previous research, Fatih and colleagues reported a MMSE score of 27 on the chronic alcoholics, in line with our study. Manning and colleagues obtained a score of 26.63, which were similar to our findings.
Numerous studies have discovered that impulsivity may be addressed as a result of alcohol consumption in the mechanism of frontal lobe dysfunction and glutamate-gamma-aminobutyric acid neurotransmission imbalance.,
For checking the impulsivity, BIS-11 was applied, the alcohol group scored a mean of 80.36, whereas the control group scored a mean of 73.48, showing a greater impulsivity in the alcoholics, as they had a greater value. The findings of our study are in agreement with the previous research, which has shown that longer periods of alcohol dependence and severity are linked to higher levels of cognitive impulsivity. The degree of alcohol dependency was shown to be the second most important predictor of global impulsivity in a multifactorial regression model for the prediction of BIS score. The bulk of the identified connections is related to cognitive (attention and lack of planning) rather than behavioral aspects of impulsivity, which is intriguing. Another research of the same individuals revealed that genetic factors impacted behavioral impulsivity (as measured by the stop-signal test), but not the BIS. This provides a unique and fascinating perspective, suggesting that although behavioral impulsivity is connected to heredity, cognitive impulsivity is largely influenced by demographic and psychosocial factors.
The Stroop test is commonly used to assess cognitive skills in individuals who are alcoholics. This tests the subject's capacity to pay selective and focused attention, as well as his or her ability to actively reject irrelevant information while selectively enhancing relevant information retained in his or her memory. It is thought to be a measure of executive processes, which include mental control and reaction flexibility. Our study showed a significant Stroop Effect in statistical analysis with a mean score of 187.16 seconds by the alcohol subjects vis-a-vis 146.92 seconds in the control subjects.
Although research comparing alcohol-dependent individuals to social drinkers and heavy drinkers to moderate drinkers indicate substantial variations in Stroop test performance, which is in agreement with our results, a meta-analysis study of executive function in alcoholics and social drinkers has yielded mixed results on Stroop Test. There is no consensus on how quickly abstinence improves cognitive functioning. When the 85 alcohol-dependent participants were compared to a non-alcohol-dependent normal group, they all performed below average. This was in agreement with our study of having a positive relationship of age and the Stroop effect. The alcoholics were shown to be impaired in a wide variety of executive domains in the Ratti et al. study with statistically significant differences, with the exception of the Stroop test. There was no significant difference in Stroop Test performance between the two groups when executive functions were examined. The Pearson correlation test, which was used to compare Stroop Test results with age and cumulative drinking, yielded no results. Another interesting finding in our study was the positive relationship that we could infer with the association of the Stroop effect and the income of the subjects.
After using the WCST-64, there was a significant result on the executive functioning between the two groups in all the aspects of the variables of the test (cf. Stroop test vide supra). A large amount of data show that fundamental cognitive activities affect WCST performance. As a result, examining the link between the WCST and other tasks that assess a variety of cognitive functions may aid in understanding the underlying mechanisms that lead to its performance. This is backed up by previous research that suggests that executive function impairments in the frontal lobe, as measured by the WCST, are common in alcohol dependence syndrome.
The findings supported previous study by demonstrating that alcohol-dependent people performed much worse in prefrontal function tasks than healthy controls. The attention/executive function category comprised tasks that assessed the ability to shift on a trial making test, as well as executive function and cognitive flexibility. Although these data showed that alcohol-dependent people's attention and executive function were impaired, there was no evidence that abstaining from alcohol for a long period of time had a detrimental influence on frontal lobe performance. These findings are consistent with previous findings by French neuropsychiatrists on 31 alcohol-dependent individuals along with 28 controls who found that alcohol-dependent individuals' performance on the Trail making test and WCST was hindered. As a consequence, the authors hypothesized that subcortical atrophy in the cerebello-thalamo-cortical circuits had a detrimental influence on frontal functioning, impairing executive function.
In an Indian study of alcohol-detoxified individuals, there were significant impairments in the following areas of the WCST: perseverative response, non-perseverative response, non-perseverative mistakes, perseverative errors, concept formation, and category completion. It suggests that those who are addicted to alcohol, do poorly on the exam, suggesting that the DLPFC and superior medial frontal areas are disrupted or delayed in development. WCST is linked to good functioning of the dorsolateral prefrontal and superior medial frontal regions. Adults with DLPFC lesions performed poorly on working memory tasks, and their level of performance was also consistently low on the WCST, indicating greater involvement of the right than left dorsolateral prefrontal cortex in response selectivity tasks. Cognitive processes (executive functions and working memory) are significantly impacted by the substance taken by the population. A significant alteration in cognitive performance in alcohol-dependent persons compared to non-addicts was observed in a sample of 312 with a 2-year follow-up period.
There is enough evidence to show that excessive use of alcohol is associated with increased cognitive deficits that can persist after cessation of drinking. The executive functioning deficits among the cognitive impairment are most likely to affect rehabilitation success and hence the important lessons that we learned from the above study which needs to be continued on a larger scale incorporating the under-mentioned limitations.
The sample size is small and it is not possible to generalize the findings in alcohol-dependent population. The role of drugs especially benzodiazepines on cognition has not been considered. The assessment was made by the investigator which may introduce interviewer bias. Comorbid personality disorders including impulsivity have not been studied and its influence on cognitive functions cannot be ruled out.
| Conclusion|| |
Long-term alcohol consumption affects executive functions considerably. The current study showed significant cognitive deficits in individuals with alcohol dependence mainly in executive functions, working memory, and high impulsiveness. The current study showed very promising results in support of the previous literature, suggesting that significant cognitive deficits were noticed in individuals with alcohol dependence mainly in working memory and executive functions like decision-making, concept formation, abstract reasoning, and ability to shift cognitive strategies in response to changing an environment and high impulsiveness. These findings may have several implications on diagnosis, treatment, in reducing relapses, and early prevention interventions
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]