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Improving Risk Assessment for Cognitive Impairment in Drug and Alcohol Clients

South Eastern Sydney Local Health District
Project Added:
9 December 2016
Last updated:
22 December 2016

Improving Risk Assessment for Cognitive Impairment in Drug and Alcohol Clients


This project used the Montreal Cognitive Assessment (MoCA) screening tool, to assess cognition in 120 clients attending an outpatient opioid treatment program. The project also identified key risk factors (such as loss of consciousness) that were related to cognitive performance in this group.


To identify cognitive deficits in a sample of clients attending an outpatient drug and alcohol service, and determine which factors in a risk questionnaire relate to poorer cognitive performance.


  • Provides up-to-date data on the extent of cognitive impairment in drug and alcohol clients.
  • Identifies at-risk clients who require further assessment.
  • Determines key questions to ask during the screening process, to identify cognitive impairment.
  • Improves the efficiency and accuracy of cognitive screening.


Cognitive impairment in people with substance use disorders is extremely common. Symptoms include difficulties with attention, memory and problem-solving, which impact their ability to function on a daily basis. Cognitive deficits may also impact how well an individual engages with drug and alcohol treatment, as people with memory and thinking difficulties can have poorer adherence to outpatient treatment programs.

Despite the recognised impact of cognitive deficits on treatment outcomes, screening tools are not typically used in evaluations of these clients in substance use settings. South Eastern Sydney Local Health District (SESLHD) uses a screening tool within the Community Health and Outpatient Care (CHOC) electronic medical system, which includes questions about risk factors thought to be related to cognitive impairment (such as substance use, overdoses and head injuries). However, the questions were not validated in a substance use setting and it wasn’t clear whether they accurately identified clients who have cognitive impairment.

It was determined that reviewing the risk assessment process using a recognised screening tool and a more detailed questionnaire, would:

  • describe the characteristics of a treatment-seeking substance use group, in terms of their level of cognitive impairment and their exposure to risk factors
  • assess the ability of particular questions from the CHOC screening tool and a more detailed questionnaire, to identify clients with cognitive impairment.


  • The MoCA screening tool was selected for this cohort. It’s a brief cognitive screening tool for mild cognitive impairment and takes around 15 minutes to administer. It tests many aspects of cognition, including memory, attention and language. Scores on the MoCA range from 0 to 30, with a score of 26 and higher generally considered normal. This tool was selected as it’s free and accessible online, and has shown to be sensitive to cognitive impairment in a substance use context.
  • A risk factor questionnaire was developed in consultation with experts in the field of cognition and substance use. It comprised original questions from the CHOC tool as well as additional questions about risk factors related to cognitive impairment, such as seizures. The questionnaire takes 5-10 minutes to administer.
  • Ten staff members from the Opioid Treatment Unit were trained to administer the MoCA screening tool by a clinical neuropsychologist. They asked existing clients to complete the screening and questionnaire during one of their regular visits.
  • The clinical neuropsychologist reviewed the results and identified whether any clients needed further assessment. A researcher collated the data and ran statistical analyses.

Project status

Implementation -the initiative has been piloted.

Key dates

September 2015 – May 2016

Implementation sites

Opioid Treatment Unit, The Langton Centre, SESLHD


  • 85% of opioid treatment program clients agreed to participate in the project.
  • There was a high prevalence of cognitive deficits in clients, with clients experiencing multiple risk factors for cognitive impairment. However, only items from the original CHOC screening tool were associated with poorer cognitive performance.
  • The average MoCA score was 24.3 (SD = 4.3). 53% of the sample scored below the validated cut score (less than 26) for suspected cognitive impairment.
  • Higher education and a higher self-rated ability to complete daily living activities were positively correlated with MoCA scores.
  • Methadone treatment was a significant predictor of falling below the MoCA cut score, compared to suboxone.
  • Clients who had experienced loss of consciousness for more than 24 hours were significantly more likely to fall below the cut score, with other risk factors including a history of seizures and current anxiety.
  • The team identified a need to refine the original CHOC screening tool to include factors that were found to predict cognitive deficits, including questions about the client’s level of education, whether they had experienced loss of consciousness for more than 24 hours and their seizure history. This may flag clients who are most at risk of cognitive deficits.
  • A revision of the pilot study would ideally include other service users (such as those seeking alcohol treatment) and include more questions about past and current substance use, to determine if those factors were related to cognitive performance.

Related resources


Dr Lauren Monds
Drug and Alcohol Services
South Eastern Sydney Local Health District
Phone: 02 9332 8732

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