Neuropsychological impairment detected by the Montreal Cognitive Assessment monitors recovery and predicts treatment dropout in substance use disorders.

Posttraumatic stress disorder (PTSD) is frequently comorbid with substance use disorder (SUD) in individuals seeking treatment for substance use. Further, SUD and PTSD are individually associated with cognitive impairment (CI) and poor treatment outcomes. Despite the frequent use of the Montreal Cognitive Assessment (MoCA) as a screening tool for CI, the validity of the MoCA has not been established in individuals with comorbid SUD-PTSD. We assessed the criterion validity of the MoCA in 128 participants seeking inpatient medically-assisted detoxification using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) as a reference for CI. The correlation between the RBANS and MoCA was weaker in those with SUD-PTSD (r = .32) relative to SUD alone (r = .56). Receiver operating characteristic (ROC) curves demonstrated that the MoCA had moderate-to-high ability to discriminate CI in individuals with SUD alone, with an area under the ROC curve of .82 (95% CI .69–.92) and optimal cutoff score of ≤23. However, in individuals with comorbid SUD-PTSD, the ROC analysis was not significant. Results suggest that PTSD, when comorbid with SUD, reduces the criterion-related validity of the MoCA. We recommend exercising caution when classifying CI in individuals with SUD-PTSD using the MoCA and suggest reducing the cutoff score to ≤23 in order to limit the rate of false-positive CI diagnoses in SUD-PTSD populations.

To date, there has not been a time-efficient and resource-conscious way to identify cognitive impairment in patients with substance use disorders (SUDs). In this study, we assessed the validity, accuracy, and clinical utility of a brief (10-min) screening instrument, the Montreal Cognitive Assessment (MoCA), in identifying cognitive impairment among patients with SUDs. The Neuropsychological Assessment Battery-Screening Module, a 45-min battery with known sensitivity to the mild to moderate deficits observed in patients with SUDs, was used as the reference criterion for determining agreement, rates of correct and incorrect decision classifications, and criterion-related validity for the MoCA. Classification accuracy of the MoCA, based on receiver operating characteristic (ROC) analysis, was strong, with an area under the ROC curve of 0.86, 95% confidence interval [0.75, 0.97]. The MoCA also showed acceptable sensitivity (83.3%) and specificity (72.9%) for the identification of cognitive impairment. Using a cutoff of 25 on the MoCA, the overall agreement was 75.0%; chance-corrected agreement (kappa) was 41.9%. These findings indicate that the MoCA provides a time-efficient and resource-conscious way to identify patients with SUDs and neuropsychological impairment, thus addressing a critical need in the addiction treatment research community.

Cognitive impairment is common among hemodialysis (HD) patients and is associated with poor treatment compliance and mortality. The aim of this study is to evaluate relatively young HD patients with less comorbidities using the Montreal Cognitive Assessment (MoCA) and identify clues for earlier detection of cognitive impairment with the help of cognitive subscale scores. A total of 103 chronic HD patients (mean age 48.3years) and 37 stage-3 to 5 chronic kidney disease (CKD) patients with similar demographics were included. Patients with cerebrovascular disease, dementia, depression, malignancy, and infections were excluded. All participants were tested with MoCA. Patients with an MoCA global score <24/30 were considered cognitively impaired. Groups were compared for MoCA subscales and clinical features. 75 patients (72.8%) in the HD group and 19 in the CKD group (51.3%) had impaired cognition. The number of patients with cognitive impairment was significantly higher in the HD group compared with the CKD group (p=0.024). The mean total MoCA score was lower in the HD group (p=0.043). MoCA subscale analysis revealed that the mean score for visuospatial/executive domain was significantly lower in the HD group (p=0.001). In this study, we showed that cognitive impairment was more common in HD patients compared with predialytic CKD patients. This difference was predominantly related to the difference in executive scores. We may think that young HD patients with less comorbidities are also at risk for cognitive impairment. Noticing progressive declines in MoCA cognitive domains, before the development of global cognitive impairment, could be beneficial for HD patients. .

Long-standing hypoglycemia can cause cognitive impairment, and whether recurrent severe hypoglycemia impacts cognitive function in patients with insulinoma has not been studied. This study focused on exploring the cognitive function in patients with insulinoma. A prospective study was conducted to assess cognitive function in patients with insulinoma by administering the Montreal Cognitive Assessment (MoCA) questionnaire between January 2016 and July 2017, and patients with cognitive impairment were followed up to undergo the MoCA test 1 year after surgery. The MoCA scores after surgery were compared with the scores before surgery, and the associations between cognitive impairment and relevant factors were further evaluated by multiple linear regression analysis. Eighteen out of thirty-four patients (53%) with insulinoma were screened positive for cognitive impairment as defined by a MoCA score <26. Performance in certain cognitive domains, including visuospatial and executive functions, delayed memory, attention, language, and abstraction, was significantly worse in patients with cognitive impairment. Multivariate analysis indicated that MoCA scores correlated significantly with tumor grade and years of education. Eight patients with cognitive impairment were lost to follow-up. The remaining ten patients with cognitive impairment showed improvements 1 year postoperatively, and seven patients recovered to normal cognitive function. Cognitive impairment was found in patients with insulinoma and was reversible in some patients 1 year after surgery. More studies are needed to explore the underlying mechanisms of the existence and reversibility of cognitive impairment in patients with insulinoma.

See Article, p 308 The impact of substance use disorders (SUDs) on the management of anesthesia for patients undergoing surgical procedures covers a broad spectrum, from the acute effects of intoxication to chronic effects such as altered anesthetic drug metabolism or a predisposition to perioperative organ injury.1 SUDs, which are characterized by the persistent use of a substance despite adverse consequences, including health problems, are extremely common. For example, in the United States, the 12-month prevalence of alcohol use disorder is 13.9%.2 For the less common substances encompassed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) SUD definition (amphetamines, cannabis, club drugs, cocaine, hallucinogens, heroin, nonheroin opioids, sedative/tranquilizers, and/or solvent/inhalant use disorders), the 12-month prevalence is still 3.9%.3 The immediate dilemma for the anesthesiologist presented with a urine toxicology result that is positive for cocaine, or any of the substances included in the DSM-5 SUD definition, is then whether to (1) postpone the elective surgery or (2) proceed with the anesthetic while anticipating potential problems associated with the urine toxicology result. While option (1) may seem the "safest" from a provider's point of view, unanticipated cancellations of surgery come at steep costs. In addition to the financial implications of unused operating room time, prolonged patient suffering, worsened patient experience, and treatment delays resulting in worsened clinical outcomes due to disease progression represent potential consequences to case cancellations.4 The higher prevalence of SUDs in socioeconomically disadvantaged populations5 with limited access to care makes a decision to postpone an elective procedure even more consequential. The acutely cocaine-intoxicated patient may display hypertension, tachyarrhythmias, myocardial ischemia, and convulsions, and management of anesthesia in such patients has been described for parturients, fetuses, and neonates.6 Cocaine-using patients presenting in a clinically nontoxic (asymptomatic) state, defined as normal blood pressure, heart rate, temperature, and normal or unchanged electrocardiogram, have been shown to receive general anesthesia safely for scheduled elective surgery in a prospective cohort study including 40 cocaine-positive patients.7 In the current issue of the Journal, Moon et al8 report on a single-center prospective cohort study evaluating the association of a positive preoperative urine test for cocaine and intraoperative hemodynamic events in a cohort of 327 asymptomatic patients with a history of cocaine use. Hemodynamic events were defined as a mean arterial blood pressure of <65 or >105 mm Hg, or a heart rate of <50 or >100 beats per minute. They found that the 173 asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia had similar percentages of intraoperative hemodynamic events when compared to 154 cocaine-negative patients. Moon et al's8 current study adds to a growing body of literature suggesting that urine toxicology results positive for cocaine, per se, may not reflect an absolute contraindication to proceeding with a surgical procedure.7,9,10 While this is undoubtedly a critical conclusion, we would like to contextualize these results with respect to (1) the prevalence of polysubstance use, particularly multiple stimulants, and (2) the effectiveness of in-hospital interventions on SUD trajectories in general. POLYSUBSTANCE USE A complicating factor for patients with cocaine use disorder is the concomitant use of other substances. Accordingly, patients with polysubstance use (except marijuana) were excluded from Moon et al's8 study. However, a patient presenting with a urine toxicology result positive for cocaine plus an additional substance may be quite common. For example, in a sample of 706 rural methamphetamine users in the United States, 35% reported using both methamphetamines and cocaine.11 The example of concurrent cocaine and amphetamine use (which could also be present among cocaine users who use prescription stimulants) illustrates why surgical patients with polysubstance use may demand a more conservative approach. Since both substances can lead to a hypermetabolic state, including tachycardia, hypertension, and hyperthermia, the risk for adverse perioperative outcomes is amplified in these patients. Specific conditions such as serotonin syndrome may further be triggered by preoperatively administered medications and pose a unique risk to polysubstance users. An isolated positive urine toxicology result for cocaine in an otherwise asymptomatic patient may lead to alterations in the anesthetic care plan, but not necessarily postponement of the surgical procedure. However, the detection of other substances in addition to cocaine may still merit delaying an elective procedure, even if the patient appears asymptomatic. Obtaining urine toxicology results as a part of the preoperative assessment in patients at risk for SUD is a requirement to make an informed decision on whether or not to proceed with surgery. IN-HOSPITAL INTERVENTIONS ON SUDS SUDs may have contributed to the presenting complaint that necessitated a surgical procedure and pose challenges to the recovery process after anesthesia and surgery. Hospitalizations, in general, offer the opportunity to administer interventions beyond the primary admission diagnosis, especially in populations that are otherwise unlikely to seek regular primary care. The standard of care in this setting is screening, brief intervention, and referral to treatment (SBIRT), which quickly assesses the severity of a patient's substance use, identifies the appropriate level of treatment, and attempts to increase insight regarding substance use and motivation for behavioral change. SBIRT can be implemented by a wide range of health care personnel with varied backgrounds. The efficacy of SBIRT has been well described for common SUDs. A Cochrane review on the effectiveness of interventions for smoking cessation in hospitalized patients found that only high-intensity behavioral interventions that began during a hospital stay and lasted a minimum of 1 month after discharge were effective.12 Interestingly, interventions of low intensity or shorter duration were not successful in this study. Yet, brief interventions administered in the preadmission clinic before elective surgery have shown success in reducing smoking rates at 1 year with a number needed to treat of 5.9.13 Similarly, for perioperative alcohol use, a recent Cochrane review summarized the results of 3 clinical studies.14 The authors found that alcohol cessation interventions significantly increased the number of participants who quit drinking alcohol during the intervention period and likely reduced the number of postoperative complications.14 SBIRT approaches have been successfully implemented across a variety of different health care sites, including emergency departments and urgent care centers, inpatient hospital settings, and outpatient and community-based clinics, and have shown success in regard to reducing cocaine use specifically.15 SBIRT has also been shown to improve functioning in other domains that may have been associated with the initial complaint that brought the patient to medical attention, including general health, mental health, employment, housing status, and criminal behavior.15 Thus, postoperative hospital-based intervention for SUDs following a positive urine toxicology result for cocaine or another substance may decrease future substance use and increase the likelihood that patients adhere to postoperative care recommendations and do not require subsequent readmission. FUTURE DIRECTIONS The study by Moon et al8 may help anesthesiologists who must make a challenging decision when faced with the dilemma of canceling versus proceeding with a scheduled case in a patient with cocaine use disorder and an isolated positive urine toxicology result. In addition to safely shepherding our patients through the intraoperative course, opportunities for expansion of our practice exist. Future study may focus on how to best manage patients presenting with polysubstance use, as well as hospitalization-based interventions geared at the long-term reduction of illicit drug use in these patients. DISCLOSURES Name: Karsten Bartels, MD, PhD. Contribution: This author helped write and revise the manuscript. Name: Joseph P. Schacht, PhD. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Richard C. Prielipp, MD, MBA.

Substance use disorders (SUDs) are frequently associated with cognitive impairment, but the specific clinical and sociodemographic factors that contribute to these deficits remain insufficiently characterized. This study aimed to examine cognitive performance in a sample of treatment-seeking patients with SUDs and to identify predictors of impairment. Eighty abstinent outpatients were consecutively recruited and underwent clinical and neuropsychological evaluation. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA), which evaluate attention, executive function, memory, language, visuoconstructional skills and orientation and the Complutense Verbal Learning Test (Test de Aprendizaje Verbal España-Complutense; TAVEC) to measure learning and memory. Overall, patients showed deterioration in several cognitive domains. Educational attainment and the duration of problematic substance use emerged as the strongest predictors of performance, particularly in attention, identification, and language. Age and abstinence length were also associated with selected domains, highlighting their role in the trajectory of cognitive recovery. Exploratory analyses suggested that the primary substance reported (alcohol or cocaine) may influence memory outcomes, although interpretation is limited by the high prevalence of polysubstance use. These findings emphasize the relevance of considering educational background, clinical history, and abstinence when assessing cognitive function in SUD populations, and suggest that strengthening cognitive reserve could mitigate neuropsychological deficits and improve treatment outcomes.

Let's focus on the insula in addiction: A refined anatomical exploration of insula in severe alcohol and cocaine use disorders.

The comparative ability of the Montreal Cognitive Assessment (MoCA) and MMSE to detect mild cognitive difficulties was investigated in 107 older adults. The sensitivity of the MoCA to detect cognitive impairment with a cutoff score of <26 was investigated, as compared to the MMSE across all scores, and at a cutoff of ≥27. Performance on MoCA subtests was compared at these MMSE cutoffs to determine profiles of early cognitive difficulties. The MoCA detected cognitive impairment not detected by the MMSE in a high proportion of participants, and this impairment was evident across various subtests. The MoCA appears to be a sensitive screening test for detection of early cognitive impairment.

Mild Cognitive Impairment: A Tricky but Relevant Diagnosis

Cognitive impairments induced by substance use contribute to poorer treatment outcomes among patients with substance use disorder (SUD). Neuropsychological assessments are often neglected during patient evaluation in SUD treatment programs owing to the fact that they require extensive time for evaluation and are resource intensive. This inattention is likely to compromise comprehensive treatments which would offer better prognosis for such patients undergoing treatment for SUD. The main objective of this study was to determine predictors of neuro cognitive disorders (NCD) in patients with substance use disorders enrolled in rehabilitation centers in Kiambu County, Kenya. A cross-sectional design was adopted and data collected between Oct-23 to Jan 2024, covering a total of 250 patients aged 18-65 years that consented to participate in the study. Consecutive non-probability sampling technique was deployed in the recruitment of the respondents into the study. A self-rated questionnaire was developed for data collection whereas the Montreal Cognitive Assessment (MoCA) Tool was employed in the screening for cognitive impairment. The prevalence of cognitive impairment was 34.8% (Prevalence per primary substance showed alcohol=37%, .cannabis=22%, and khat=22%). Age Coefficient=0.0852, P=0.013 CI= 0.018- 0.152), education (Coefficient=0.0783, P&lt;0.008 CI= 0.021-0.139), and anxiety disorder (Coefficient=0.4286, P&lt;0.001 CI= 0.317- .540) were found to be significantly associated with neurocognitive disorders at multivariate analysis. This shows that it is important to screen for cognitive impairments during early treatment stages considering the high prevalence rate. This will enhance the choice of treatment course and maximize on treatment outcomes.

The objective of this study was to determine the test–retest reliability; construct and criterion validity; and test operating characteristics of a newly developed cognitive impairment risk factor screening instrument, the Alcohol and Drug Cognitive Enhancement (ACE) Screening Tool. Participants in the validation study were 129 adults with substance use disorder (SUD) enrolled in residential SUD treatment services and 209 normal controls. Test and retest data were available for 36 participants with SUD and 40 normal control individuals on the ACE Screening Tool. Test–retest reliability was excellent (ICC = 0.97). The ACE Screening Tool was significantly correlated with the Montreal Cognitive Assessment (MoCA), Behavior Rating Inventory of Executive Functioning—Adult Version (BRIEF-A), Test of Premorbid Functioning (TOPF) and Five Point Test, establishing construct validity. Criterion validity was established using a ternary severity variable constructed using results obtained on the MoCA and BRIEF-A. Test operating characteristics analysis showed 93% sensitivity, 46% specificity, 33% positive predictive power, and 96% negative predictive power using a cut-score of >3. Those high levels of sensitivity and negative predictive power indicated that the tool would likely detect cognitive impairment when present and should therefore be considered suitable as an initial screening tool for cognitive impairment in individuals attending SUD services.

Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used. This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates. Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor. The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.

Offspring of parents with alcohol use disorder (AUD) have elevated risk of substance use. However, few studies have comprehensively assessed risks associated with different substances. This study investigated the risk of substance use disorders (SUDs) in adult children with severe parental AUD over four decades, contributing information on the risk of each disorder, the roles of important risk factors, and the general versus substance-specific nature of SUD risk. Swedish national register data were used to follow children with and without ≥ 1 parent with an inpatient diagnosis of AUD from 1973 to 2018 to investigate risk of alcohol, opioid, cannabinoid, sedative/hypnotic, cocaine, other stimulant, hallucinogen, volatile solvent, and multiple drug use disorder. The composite outcomes any SUD, 1 SUD, and ≥ 2 SUDs including and excluding AUD were also investigated. Severe parental AUD and outcomes were defined with hospital inpatient diagnoses (ICD codes). Hazard ratios (HRs) were calculated with Cox regression. Model 1: unadjusted. Model 2: adjusted for child’s sex, parental education, and parental mortality. Model 3: Model 2 plus parental SUD. Model 4: Model 3 plus parental psychiatric disorder. Risks of all outcomes were higher in those with (n = 99,723) than without (n = 2,321,756) severe parental AUD. For SUD diagnoses, the highest unadjusted risks were for other stimulant (HR 5.33, 95% CI 5.03–5.64), volatile solvent (HR 4.95, 95% CI 3.98–6.15), and opioid (HR 4.62, 95% CI 4.37–4.87) use disorders. After full adjustment, risks declined, and HRs of the different diagnoses converged to approximately twice as high in the adult children of parents with AUD. Risks of any SUD and of ≥ 2 SUDs were more elevated (95% CIs did not overlap) when AUD was included than when AUD was excluded. Risk of ≥ 2 SUDs was higher than risk of 1 SUD, but only when AUD was included. Severe parental AUD was associated with elevated risk for all SUDs. After full adjustment, SUD risks declined and converged but remained doubled. Sociodemographic factors, parental SUD, and parental psychiatric disorder explained much of the excess risk. Drug combinations that included alcohol elevated the risk of ≥ 2 SUDs and any SUD.

BackgroundEarly identification of Alzheimer’s disease (AD) is critical for disease‐modifying therapies. The Davos Alzheimer’s Collaborative flagship program tested the feasibility of implementing a digital cognitive assessment (DCA) followed by a blood biomarker (BBM) for early detection of cognitive impairment (CI).MethodIndividuals ≥65 years without dementia were approached via their primary care provider (PCP) or through direct‐to‐consumer (DTC) social media. After consenting, participants completed the Cogstate Brief Battery (CBB) DCA. Participants with an abnormal or borderline CBB score were offered the Montreal Cognitive Assessment (MoCA) and the PrecivityAD® blood test, a CLIA‐certified laboratory developed test that uses mass spectrometry to analyze biomarkers to identify brain amyloid plaques (reported by the Amyloid Probability Score‐APS) in individuals with CI.ResultOver 2300 participants expressed interest. Of 2001 eligible, 1076 (96% social media, 4% PCP) e‐consented. 742 completed the CBB of which 211 (28%) were borderline, 113 (15%) abnormal, and 418 (56%) were negative for CI. Of the 324 with borderline or abnormal CBB scores, 219 (67%) completed the MoCA (59% Normal range, 38% Mild CI range, 2% Moderate CI range, and 0.5% Severe CI range). Of the 324, 218 (67%) received BBM: 18.8% had High APS, 67.9% Low APS, and 13.3% Intermediate (e.g. non‐informative) APS. The APS result for participants with a normal MoCA showed 20% with High APS, 12% with an Intermediate APS, and 69% with Low APS. Of those with an impaired MoCA 18% had High APS, 15% Intermediate and 67% low APS. A Fisher’s Exact test determined there was no statistically significant relationship between MoCA impairment and APS category (p‐value 0.68).ConclusionThis study highlights the success of a DTC approach. The MoCA, alone, is insufficient to identify risk of AD in individuals with CI. A more comprehensive clinical evaluation of AD can be enhanced with the addition of a BBM leading to better disease‐modifying strategies.

A multicenter study to validate the Brief Cognitive Status Examination as a screening tool for the detection of cognitive impairment in a substance use disorder population over 45 years of age in a Spanish population.