Alcohol-related cognitive impairment

Many people with alcohol problems experience alcohol-related cognitive impairment (ARCI). This includes difficulties with:

remembering
concentrating
reasoning
processing information
planning ahead
sense of direction

This can be due to dementia, stroke or traumatic brain injury. But in people attending alcohol services, alcohol is usually the cause.

In this guide, you can find out about:

Why older adults are more at risk

Older adults with alcohol problems are more likely to have alcohol-related cognitive impairment than younger people with alcohol problems.

This is because older adults are more likely to:

take medication that, when mixed with alcohol , harms the liver and increases alcohol’s toxic effects on the brain
experience falls and injuries that cause traumatic brain injury or blood vessel damage
have a stroke
experience loss of appetite, poor nutrition and thiamine deficiency, associated with alcohol-related brain conditions like Wernicke’s Encephalopathy and Korsakoff Syndrome
experience of repeated alcohol withdrawal which can become more severe and longer-lasting in adults, and is associated with cognitive impairment

Cognitive impairment caused by thiamine deficiency or the direct toxic effect of alcohol is often reversible if the person stops or greatly reduces their drinking.

This is not the case for cognitive impairment caused by traumatic brain injury or vascular damage. But people with these conditions can still benefit from harm-reduction strategies.

Barriers to treatment

People with cognitive impairment often experience barriers to alcohol treatment.

This may be because they find it difficult to:

know they need help
give an accurate alcohol history
remember appointments
make decisions
cope with social interactions or explain things to others
manage their emotions and learn new coping skills

In fact, at Drink Wise Age Well, people with cognitive impairment are just as likely to be treated successfully as people without cognitive impairment.

But this can only happen if people are screened for cognitive impairment when they enter services. You may also need to adapt the kind of support they get.

NICE, Public Health England and the Scottish Government all recommend routine screening for cognitive impairment in alcohol services.

One option is a validated screening tool called the Montreal Cognitive Assessment (MoCA).

MoCA is available for free, but you’ll need to complete a paid-for online training course before you can use it.

Find out more about the MoCA cognitive screening tool

When discussing this with a patient, you should reassure them that:

it’s not an intelligence test, and most people don’t get all the questions right
any difficulties they’re having may be temporary and caused by their alcohol use
it can’t give a definitive diagnosis of cognitive impairment — it only suggests that they might be having difficulties at that moment in time

If screening suggests that someone has a cognitive impairment when they enter treatment, they should be screened again if they stop or greatly reduce their drinking.

If this shows that their cognitive function has improved, it can encourage them to maintain a lower level of drinking.

If there’s no improvement, they can be referred for a specialist assessment through their GP, community mental health service or specialist addiction service.

Adapting support for people with cognitive impairment

Once you’ve identified someone with cognitive impairment, here are some practical steps you can take to make sure you’re meeting their needs.

Always introduce yourself clearly and explain your role. Repeat yourself and clarify details if necessary.
Consider the person’s attention span. Offer breaks and give them more time to answer questions.
Simplify appointment letters and other written material. Make them short and to the point.
Give information in more than one way. Consider using role playing, visual aids or practical demonstrations. Use labels and post-its if appropriate.
After group sessions, speak to the person one-on-one. Review the session and make sure they have understood.
Offer home visits and arrange transport for people who can’t drive.
Offer notepads and encourage them to write down questions and thoughts as they occur.
Develop a wider wellbeing plan. This should include healthy eating, managing medicines and home safety.
Offer advice and support to their family. Where appropriate, include them in the wellbeing plan.

Thiamine (vitamin B1) is an essential nutrient. The body can not produce it, so people have to get it from food or a supplement.

People with alcohol problems are more at risk of thiamine deficiency due to:

poor diet and eating habits
inflammation of the stomach lining stopping thiamine absorption
liver damage that makes it harder to process vitamins and minerals

Thiamine deficiency is a common cause of alcohol-related brain damage and cognitive impairment. You should assess anyone attending alcohol services for thiamine deficiency. [

Thiamine deficiency can cause a form of brain damage called Wernicke’s Encephalopathy (WE). WE is a life-threatening medical emergency, and the symptoms are often mistaken for drunkenness.

Symptoms of WE include:

Confusion
Ataxia (loss of muscle coordination)
Vision changes, like nystagmus (abnormal back-and-forth eye movements), double vision or eyelid drooping

People with WE symptoms should be given thiamine through a drip or injection as soon as possible to prevent death or permanent brain damage.

You should also offer thiamine to people who:

are malnourished or at risk of malnourishment
have symptoms of liver disease
are in acute alcohol withdrawal
are preparing for a medically assisted alcohol withdrawal

Cognitive impairment and mental capacity

Older adults with cognitive impairment do not necessarily lack the capacity to make informed choices.

They may have the mental capacity to decide some things (like what to wear) but not others (like how to manage their finances). Their capacity may also vary over time.

If somebody has capacity and refuses treatment, the law says their decision must be respected. But it’s worth asking them again at other times, as they may change their answer.

Always start by assuming that someone does have the capacity to make decisions. A GP or other health professional can give someone a full assessment of their mental capacity.

When someone has been abstinent for a while, it’s important that they receive another capacity assessment as their mental capacity may have changed.

If somebody does lack capacity, they can still benefit from alcohol treatment. But this might have to be given as part of a multi-agency care package in line with legal frameworks.

Where to go for more information

Find out more about alcohol, dementia and cognitive impairment from: