Screening Tools for Cognitive Impairment in Adults with Substance Use Disorders: A Systematic Review

Abstract

Objectives: Cognitive impairment is common in individuals with substance use disorders (SUDs), yet no evidence-based guidelines exist regarding the most appropriate screening measure for use in this population. This systematic review aimed to (1) describe different cognitive screening measures used in adults with SUDs, (2) identify substance use populations and contexts these tools are utilised in, (3) review diagnostic accuracy of these screening measures versus an accepted objective reference standard, and (4) evaluate methodology of included studies for risk of bias. Methods: Online databases (PsycINFO, MEDLINE, Embase, and CINAHL) were searched for relevant studies according to pre-determined criteria, and risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies–2 (QUADAS–2). At each review phase, dual screening, extraction, and quality ratings were performed. Results: Fourteen studies met inclusion, identifying 10 unique cognitive screening tools. The Montreal Cognitive Assessment (MoCA) was the most common, and two novel screening tools (Brief Evaluation of Alcohol-Related Neuropsychological Impairments [BEARNI] and Brief Executive Function Assessment Tool [BEAT]) were specifically developed for use within SUD populations. Twelve studies reported on classification accuracy and relevant psychometric parameters (e.g., sensitivity and specificity). While several tools yielded acceptable to outstanding classification accuracy, there was poor adherence to the Standards for Reporting Diagnostic Accuracy Studies (STARD) across all studies, with high or unclear risk of methodological bias. Conclusions: While some screening tools exhibit promise for use within SUD populations, further evaluation with stronger methodological design and reporting is required. Clinical recommendations and future directions for research are discussed.

Neurocognitive and substance use disorders in older adults: challenges and evidence

“…The most studied tool was the MoCA; it demonstrated the most consistent ability to detect cognitive impairment in this population. Other measures (ACE-R, BEARNI and BEAT) showed promise for use but require further studies before recommending their implementation in clinic (Ko et al, 2021).…”

“…Folstein mini-mental state examination (MMSE) (Folstein et al, 1975;Ko et al, 2021) 30-item instrument Assesses orientation to time and place, registration, attention, concentration, recall, language, repetition and complex commands Screens for Alzheimer's and other types of dementia Disadvantage: may be culturally biased, failed to demonstrate adequate classification accuracy in the context of SUDs Addenbrooke's cognitive examinationrevised (ACE-R) (Ridley et al, 2018) Assesses attention, orientation, memory, language, verbal fluency and visuospatial skills Useful in detecting cognitive impairment in the context of SUDs Montreal cognitive assessment (MoCA) (Hobson, 2015;Copersino et al, 2012) 30-item instrument Assesses short-term memory recall, visuospatial abilities, executive functions, attention, concentration, working memory, language, abstract reasoning and orientation to time and place Has good specificity (87%) and sensitivity (90%). More sensitive than MMSE in assessing mild-to-moderate cognitive impairment Detects cognitive impairment in the context of substance use Predicts clinically relevant behaviors among older adults with SUDs Disadvantage: may have cultural and educational biases Mini-Cog (Borson et al, 2000) Brief screening tool for mild cognitive impairment in older adults Has good sensitivity, specificity and negative predictive value Consists of three main steps: !…”

“…The most studied tool was the MoCA; it demonstrated the most consistent ability to detect cognitive impairment in this population. Other measures (ACE–R, BEARNI and BEAT) showed promise for use but require further studies before recommending their implementation in clinic (Ko et al , 2021). The paucity of validated screening instruments for neurocognitive and SUDs continues to hinder the identification and diagnosis of these disorders among older adults.…”

A Scoping Review of Guidelines and Quality Measures to Screen for Social and Caregiver Support and Cognitive Impairment in Primary Care

“…Through a combination of formal literature searches and reference mining of identified sources, we identified 50 references: Nine were excluded at citation screening; nine were excluded because they pertained to settings that were not relevant to the patient population or to primary care settings, did not mention cognitive assessment, or did not address assessment of CI; and ten provided background. Nineteen studies reported in 22 publications (guidelines and peerreviewed reports of studies) that addressed screening patients for CI in some way were used (American Academy of Family Physicians [AAFP], 2014; American Psychological Association, 2021; Aufill et al, 2019;Burton et al, 2021;CMS, 2022;Chen et al, 2018;Chow and MacLean, 2001;Cordell et al, 2013; Dementia Warning Signs Workgroup, Office of Geriatrics and Extended Care, and the National Center for Health Promotion and Disease Prevention, 2011;Feil, MacLean, and Sultzer, 2007;Fernandes, Goodarzi and Holroyd-Leduc, 2021;Ko et al, 2022;Koekkoek et al, 2016;LeRoith et al, 2019;Levell-Smith, 2020;Medicare Learning Network, 2021;Mini-Cog, 2016;Paraizo et al, 2016;Petersen et al, 2018;Thompson et al, 2021;Tokuhara et al, 2006;USPSTF et al, 2020). Figure 4.1 shows the PRISMA flowchart for the items that were identified.…”

“…A 2021 systematic review assessed screening tools for CI specifically for use in patients with SUD (high quality as assessed by AMSTAR 2) (Ko et al, 2022). Fourteen studies that met inclusion criteria identified ten cognitive screening tools.…”