Alcohol Use Disorder as a Risk Factor for Cognitive Impairment

Abstract

Background:

Alcohol use disorder (AUD) is a worldwide problem. The AUD can take the form of hazardous drinking, binge drinking, or alcohol dependence. The effects of alcohol on cognition can be diverse and complex.

Objective:

Our study aimed to assess AUD as a risk factor for cognitive impairment.

Methods:

A literature search was conducted using major electronic databases of PubMed, EMBASE, and Web of Science. Abstracts were screened independently to include data from original research reports. The following keywords were used: alcohol abuse, cognitive impairment, Alzheimer’s disease, and dementia. In total, 767 abstracts were retrieved. After removing the duplicates, 76 articles met the criteria for full-text review, of which 41 were included in this report.

Results:

People with AUD are seen from different geographical areas and cultures. AUD is associated with an increased risk of cognitive impairments, Alzheimer’s disease, and dementia, especially vascular dementia. In addition, AUD interacts with comorbidities increasing the risk of cognitive impairment.

Conclusion:

AUD is associated with an increased risk of cognitive impairments, which may have more than one underlying mechanism.

Keywords

Alcohol use disorder Alzheimer’s disease cognitive impairment dementia

INTRODUCTION

Alcohol use can be traced back for a long time in human history, which is an integrated part of many cultural, religious, and social practices. As the most recreationally used drug, alcohol has about 2.3 billion current users globally [1]. Available reports are inconsistent on how alcohol affects cognitive performance. While some studies demonstrated the detrimental impact of alcohol on cognition, findings from other studies showed alcohol consumption was associated with a decreased risk of cognitive impairment [2].The various effects of alcohol on cognition are due to many factors involved in its effects on cognition and/or brain health such as type of alcohol (liquor versus wine), duration of use, amount of alcohol use, and certain genetic predispositions, which vary much from person to person. In a study, daily alcohol consumption of 40 g for women and 80 g or less for men was protective and associated with a decreased risk of cognitive impairment. On the other hand, when the daily alcohol consumption exceeds 1 wine-equivalent liter among men and 0.5 liters among women, there was an increased risk of cognitive impairment [2].

Alcohol use disorder (AUD) refers to a clinical diagnosis of unhealthy drinking behaviors. According to the 2019 National Survey on Drug Use and Health, 14.5 million Americans aged 12 and older had the diagnosis with AUD [3]. It comprises hazardous drinking (i.e., drinking above recommended limits), binge drinking, and alcohol dependence. We hypothesized that AUD is associated with an increased risk for cognitive impairments including dementia. For this report, research reports on human subjects were reviewed on how AUD was related to the risk of cognitive impairment, dementia, as well as the most common form of dementia: Alzheimer’s disease. In addition, possible underlying mechanisms were discussed, which explains how a diagnosis of AUD is correlated with cognitive impairments.

METHODS

A systemic literature search was performed in December 2022 using the following databases: Medline via PubMed, Embase, and Web of Science. The following keywords were used for performing the literature search (keywords must be included in title/abstract): alcohol abuse, alcohol dependence, alcohol use disorder, cognitive impairment, Alzheimer’s disease, and dementia. The following filters were applied to perform the search as well: 1) abstracts written in English; 2) abstracts or full-text articles available; and 3) original research reports with adult human subjects only.

In total, 767 abstracts were identified from all databases. Duplicated abstracts (n = 56) and irrelevant records (n = 257) were removed before assigning them to different reviewers. After the first round of screening, 368 records were removed for a variety of causes (for example, all review articles were removed; quite a few focused on AUD or cognitive impairments but not both, which were removed as well). With the full-text reviewing stage, a total of 76 reports were assessed. Of these, 35 studies were excluded as shown in Fig. 1 [4]).

Fig. 1

A PRISMA 2020 flow diagram for the literature search.

RESULTS

AUD and cognitive impairment

For the last four decades, different studies were carried out in various geographical locations and/or cultures to investigate how AUD was associated with cognitive impairment.

In 2001, a cross-sectional study with a large Italian patient population (n = 15,807) found that alcohol abuse was associated with an increased risk of cognitive impairment among older individuals [2]. In 2014, a cohort study with 3,542 community-dwelling Australian men aged 65 to 83 years followed for 6 years reported that heavy regular drinking and alcohol abuse did not increase the risk of cognitive impairment [5]. One possible explanation is that aging as the primary risk factor for cognitive impairment might disguise the effects of alcohol consumption on the elderly participants in this study. In 2017, a 6-year-long follow-up nationwide cohort study with Korean adults (n = 5,157, aged 45 or older) found that problematic drinking behavior was associated with an increased risk of cognitive impairment/decline [6]. In addition, those with problematic drinking behavior experienced a faster cognitive decline rate than those without problematic drinking behavior [6].

Different types of cognitive impairment were reported from studies performed in different countries worldwide, which were summarized in Table 1. Two reports came from the United States of America. In 1985, DeFranco et al. reported that the duration of alcohol abuse was positively associated with cognitive deficits in psychomotor speed, recent memory, and overall alertness [7]. In 2006, Woods et al. reported that either current heavy alcohol consumption or a history of alcohol dependence (even in the absence of heavy current alcohol use) was associated with significant cognitive impairments in domains of attention/executive function, learning, memory, and motor function [8].

Table 1

Different types of cognitive impairment were observed in people with AUD

Author /Publication Year	Country	Study Design	Sample Characteristics	AUD	Cognitive Impairment	Cognitive Test
DeFranco et al., 1985 [7]	United States of America	Cross-sectional	Alcoholics (n = 125, age = 44.7±12.3)	Alcohol abuse	Long-term alcohol abuse was associated with greater cognitive deficits in psychomotor speed, recent memory, and overall alertness.	Benton Visual Retention Test; Trail Making Test (parts A and B); WAIS; Wechsler Memory Scale
Woods et al., 2016 [8]	United States of America	Cross-sectional	53.3% of the older adults (n = 66, age = 38.5±11.7) had a history of alcohol dependence.	Alcohol dependence	A history of alcohol dependence was associated with lasting cognitive impairment in attention/executive function, learning, memory, and motor function.	BVMT-R; COWAT; Grooved Pegboard Test; HVLT-R; Stroop Test; Trail Making Test (parts A and B); WAIS-III
Williams and Skinner, 1990 [9]	United Kingdom	Cross-sectional	Adult heavy drinker group (n = 19, age = 47.9±12.8) with the age-matched control group (n = 19, age = 47.3±13.9)	Heavy drinkers	Heavy drinkers had more cognitive impairments in memory, abstraction ability, verbal ability, and logical reasoning than matched controls (low alcohol group).	WAIS; WCST; Wechsler Memory Scale
Liappas et al., 2007 [10]	Greece	Cross-sectional	Alcohol dependent patients (n = 33 age = 64.8±8.3), mild stage AD (n = 38; age = 63.8±6.9), and healthy subjects (n = 73; age = 64.6±4.8)	Alcohol dependence	Impaired functions in attention, memory, visuoconstructive ability, verbal fluency, and information processing speed.	MMSE; SKT; the Clock Test; WAIS; the Verbal Fluency Test
Blanco-Presas et al., 2018 [11]	Spain	Cross-sectional	Alcohol/cocaine Abuse group (n = 19; age = 38.65±3.83); Alcohol Abuse group (n = 20; age = 38.19±4.82); Control group (n = 19; age = 37.01±5.98)	Alcohol abuse/dependence	Increased risk of impaired executive, memory, and visuospatial function in middle-aged adults	BADS; BNT; RBMT; VOSP
Ros-Cucurull et al., 2018 [12]	Spain	Cohort	Old adults (n = 33; average age = 71) with hazardous use of alcohol; Control group (n = 31, average age = 72.9) of healthy volunteers	Hazardous long-term alcohol use	Long-term hazardous use of alcohol was associated with cognitive impairment in attention, executive function, and memory.	CPT-II; COWAT; CVLT; IGT; MMSE; N-Back; RCFT; RFFT; SDMT; Stroop Test; TOL
Villa et al., 2021 [13]	Spain	Cross-sectional	Patients with AUD (n = 111, age = 48.7±9.6) and healthy controls (n = 100, age = 49.1±8.4)	AUD	Impaired functions in attention, memory, processing speed, verbal fluency, and executive function were seen in patients with moderate or severe AUD.	Attention Test D2; WAIS; CVLT; WCST; IGT; IAT; Stroop Test
Cairney et al., 2007 [14]	Australia	Cross-sectional	Heavy episodic drinking group (n = 20, age = 26.0±6.1) and the non-drinking group (n = 24, age = 23.3±5.9)	Binge drinking	The heavy episodic drinking group showed impaired attention, psychomotor speed, memory, and learning.	CogState Battery (simple reaction time, choice reaction time, monitoring, matching, working memory, incidental learning, and associated learning)
Viswam et al., 2018 [15]	India	Cross-sectional	Adult males with alcohol dependence (n = 56, age = 40.1±9.6)	Alcohol dependence	Impaired executive dysfunction	FAB; MoCA

AD, Alzheimer’s disease; AUD, Alcohol Use Disorder; BADS, Behavioral Assessment of the Dysexecutive Syndrome; BNT, Boston Naming Test; BVMT-R, Brief Visuospatial Memory Test-Revised; COWAT, Controlled Oral Word Association Test; CPT-II, Conners Continuous Performance Test II; CVLT, California Verbal Learning Test; FAB, Frontal Assessment Battery; MoCA, Montreal Cognitive Assessment; HVLT-R, Hopkins Verbal Learning Test-Revised; IAT, Implicit Association Test; IGT, Iowa Gambling Test; MMSE, Mini-Mental State Examination; RBMT, Rivermead Behavioral Memory Test; RCFT, Rey Complex Figure Test; RFFT, Ruff Figural Fluency Test; SDMT, Symbol Digits Modalities Test; TOL, Tower of London Test; VOSP, Visual Object and Space Perception Battery; WAIS-III:, Wechsler Adult Intelligence Scale-Third Edition; WCST, Wisconsin Card Sorting Test; SKT, Syndrome Short-Test.

Most of the studies on the association between AUD and different types of cognitive impairment were from European countries. In 1990, one study from United Kingdom reported heavy drinkers (n = 19) had significant cognitive deficits in memory, abstraction ability, verbal ability, and logical reasoning compared to the matched control group (n = 19) [9]. For a study comparing cognitive performance between chronic alcohol-dependent Greek patients (n = 33) and a healthy control group (n = 73), those with alcohol dependence had mild cognitive defects in attention, memory, visuoconstructive ability, verbal fluency, and information processing speed [10]. Three studies were from Spain. In the first study with middle-aged adults, the alcohol abuse/dependence group (n = 20) performed significantly poorer than the control group (n = 19) on memory, executive, language as well as visual function [11]. In the second study, compared with healthy volunteers (n = 31), impaired cognitive function in domains of attention, executive function, and memory was observed in a group of old adults (≥65 years old) with hazardous alcohol use (n = 33) [12]. In the third study, patients with AUD (n = 111) showed impaired cognitive functions in attention, memory, processing speed, verbal fluency, and executive function in comparison with healthy controls (n = 100) [13]. In addition, those who reported more impulsivity and chronic alcohol abuse and with more addiction suffered greater cognitive deterioration than those who did not [13].

In 2007, in a study on aboriginal Australians, heavy episodic alcohol users (n = 20) were shown for having impaired cognitive functions in psychomotor speed, attention, memory, and learning in comparison to non-drinkers (n = 24) [14]. In 2018, a small sample (n = 56) of Indian adults who had alcohol dependence were reported for having cognitive impairment seen in the majority and executive dysfunction in a small portion of the participants [15].

How AUD increases the risk of cognitive impairment by interacting with other morbidities?

In patients with AUD, one or more comorbidities may exist, which might affect cognition by interacting with the AUD. Type 2 diabetes is a common morbidity among those who have AUD. In a study examining if a history of alcohol abuse increased the risk of cognitive impairment in people with type 2 diabetes, participants were recruited into three comparison groups: alcoholic-diabetic (n = 15); alcoholic-nondiabetic (n = 15); and nonalcoholic-diabetic (n = 15). Type 2 diabetes and a history of alcohol abuse enhanced each other’s effect on the risk of lowering cognitive functions [16]. Specifically, comorbidities of diabetes and alcoholism significantly interacted with each other for lowering memory function [16].

Postoperative cognitive dysfunction is a morbidity commonly seen in elderly patients. In a study investigating how postoperative status interacts with a history of self-reported alcohol abuse for affecting cognitive functions, participants aged 55 years or older were recruited into four different groups: nonsurgical alcoholic (n = 14); nonsurgical nonalcoholic (n = 14); surgical alcoholic (n = 14); and surgical nonalcoholic (n = 14). Cognitive performance was assessed before (baseline) and 2 weeks after an elective surgery or a corresponding time interval for those with no surgery being done. As expected, the alcoholic group had lower scores on digital span and semantic fluency than the nonalcoholic group [17]. In addition, a history of alcohol abuse in older patients increased the risk of postoperative cognitive impairment in the domains of visuospatial abilities and executive functions [17].

Last, mental illness can interact with AUD as a comorbidity to affect cognitive ability. Approximately 50% of individuals with serious mental illness were diagnosed with AUD during their lifetime [18]. Adults with moderate to severe AUD as well as a diagnosis of serious mental illness were enrolled in one study (n = 135) to investigate whether serious mental illness and AUD severity were associated with cognitive impairment in individuals having these comorbidities. Both AUD and the severity of mental illness were positively associated with the risk of cognitive impairment [19]. However, it was not possible to delineate how severe mental illness interacted with AUD to affect cognitive performance using only one group of patients with both comorbidities.

Schizophrenia is one of the most common psychiatric illnesses. 120 psychiatric patients with a diagnosis of schizophrenia (n = 40), alcohol dependence (n = 40), or both (n = 40) were recruited in a study from the United Kingdom. Patients with a dual diagnosis of both schizophrenia and alcohol dependence had a higher rate of cognitive impairment than those with either diagnosis alone [20]. From the cognitive function perspective, the dual diagnosis group performed significantly worse on naming/repetition for the language function compared to the alcohol dependence group, and on visual construction as a measure of visuospatial skills than the schizophrenia group [20].

AUD and dementia

Two studies showed that AUD was associated with an increased risk of dementia. The first study was a population-based case-control study conducted with Canadian patients with vascular dementia (n = 129) as well as control subjects (n = 535). A history of alcohol abuse was associated with a 2.45-fold increased risk of vascular dementia [21]. The second study was conducted with female veterans in the United States of America, aged 55 years or above (n = 2,207), who were diagnosed with AUD. Female individuals with AUD were seen with an increased risk of dementia of more than three folds compared to those age-matched controls without AUD [22].

Compared to late-onset dementia, early-onset dementia was more likely attributed to alcohol use [23]. Based on a prospective cohort study carried out in London, with participants aged 35–55 years (n = 9,087), the risk of dementia was increased for those who had long-term consumption for more than 14 units/week [24].

As for cognitive impairment, patients with alcohol-related dementia (n = 14) were found for having similar executive control deficits as patients with vascular dementia (n = 13) [25]. By contrast, these patients with alcohol-related dementia did not show severe memory impairment as seen in patients with AD (n = 15) [25]. Further, in a different study with Greek patients, patients with alcohol dependence (n = 33) had the same degree of impairment in verbal fluency, working memory, and frontal functions as seen in AD patients (n = 38), but memory problems were more pronounced in the AD patients [10]. The evidence supports that AUD could increase the risk of dementia, especially vascular dementia.

AUD and AD

We further investigated if AUD could increase the risk of AD as the most common type of dementia. With a case-control study design, a population survey on aging and dementia was conducted in people in Stockholm, Sweden, specifically those classified as either who abused alcohol (n = 98) or controls (n = 216), to determine the risk factors for late-onset AD [26]. Alcohol abuse was positively associated with the risk of late-onset AD (relative risk, 4.4; 95% confidence interval, 1.4–13.8) [26]. Another case-control study was performed in Australia with participants with AD (n = 170) and their matched controls (n = 170) [27]. However, alcohol abuse was not confirmed as a risk factor for AD [27].

In a retrospective, population-based cohort study, participants had a history of driving under the influence (DUI) (n = 2,882). Arrests for DUI served as a proxy for alcohol addiction. It was found that the age of the first DUI arrest correlated with the age of AD diagnosis (coefficient = 0.7) [28]. In addition, a dose-response relationship was found between the number of DUIs and the age of AD onset, which is 9 years earlier on average in individuals than those without a history of DUI arrest [28].

For patients with AD (n = 106), based on findings from a prospective cohort study, alcohol abuse was significantly correlated with the rate of cognitive decline during a follow-up of three years [29]. In a separate report, it was found that misuse of alcohol had an additive effect on dementia severity among AD participants (n = 52) [30]. These findings suggested that AD and AUD-associated dementia might have different mechanisms although they might exist in the same individual, which is consistent with the finding that AD and AUD were associated with atrophic changes from distinct brain regions [30].

DISCUSSION

AUD is associated with increased risk for cognitive impairments, dementia, or Alzheimer’s disease. AUD also can enhance the risk of cognitive impairments with comorbidities such as diabetes, postoperative cognitive dysfunction, and mental illnesses. Alcohol can impair brain health and cognition directly as a toxic agent to the nervous system and indirectly through other mechanisms.

Alcohol has neurotoxic effects, which can cause microscopic lesions in the central nervous system and impair cognition as a sequela. For example, compared with matched controls, alcohol abusers had a significant decrease in the density of cholinergic muscarinic receptors in either the frontal (n = 79) [31] or temporal lobe (n = 26) of the brain [32]. On the cellular level, a significant loss of large neurons from the superior frontal cortex was found in alcoholic male Australians (n = 22) [33]. On the organ or gross structural level, participants with AUD (n = 67) had significantly smaller somatomotor cortical gray matter volume than those without AUD (n = 1,283) [30].

The pathological structural changes always accompany functional changes in the brain. In fact, two studies found that patients with AUD had structural lesions as well as impaired cognitive functions. In the first study, diffuse cerebral damage and impaired verbal function were seen in alcoholic Italians (n = 28) [34]. For the second study, a functional failure of the frontal lobe and the premotor area of the left hemisphere was observed in Russians with alcoholic encephalopathy (n = 30) in comparison with the age-matched controls [35].

Alcohol might impair brain health and cognition indirectly through other mechanisms. Vitamin B1 deficiency can inversely affect the metabolic rate and the energy supply of the brain. As a fact, AUD is the most common cause of vitamin B1 deficiency, whereas a lack of vitamin B1 can lead to the degenerative brain disorder: Wernicke encephalopathy. In a study with French patients with alcohol-related cognitive impairment (n = 19) or Wernicke encephalopathy (n = 6), hypometabolism was seen predominantly in the prefrontal and cingulate cortex [36].

The role of vitamin B1 (thiamine) deficiency in increasing the risk of cognitive impairments or dementia was revealed by findings from other studies. In an Indian patient group with alcohol-dependence syndrome (n = 100), cognitive impairments were improved with treatments of detoxification, multivitamin supplement, and abstinence [37]. Further, a retrospective study from Taiwan found that thiamine therapy was associated with a reduced risk for dementia development in patients with AUD (n = 5,059) compared to the control group [38].

Besides the brain, damage to other organs found in people with AUD might affect the brain health or cognition indirectly. For example, the liver is one of the most affected organs in those with AUD, which is commonly referred to as an alcoholic liver disease. As expected, cognitive impairments were commonly seen in patients with end-stage liver disease (n = 300) [39].

Finally, patients with AUD might have other associated conditions, which can impair cognition directly or indirectly. Cocaine is a well-known agent for causing cognitive impairments. At the same time, alcohol abuse is very common among cocaine users. In one study with 263 patients, 89% of those with cocaine abuse/dependence were found to qualify for alcohol or other drug dependence diagnoses [40]. Therefore, the cognitive impairments seen in patients may attribute to alcohol, cocaine, or both. In another study, participants from the Czech Republic were examined for the effects of methanol poisoning on their cognitive functions [41]. Compared to the control group (n = 57), patients with methanol poisoning (n = 50) were associated with impaired executive and memory functions, which lasted for more than 2 years after poisoning [41]. If patients with AUD had a history of consuming industrial alcohol or alcohol contaminated with methanol, the cognitive impairments could attribute to ethanol, methanol, or both.

By taking a systemic approach, our study has analyzed the data from 41 original reports on the relationship between AUD and the risk of cognitive impairments and dementia. In summary, AUD is associated with an increased risk of cognitive impairments. In addition, comorbidities can interact with AUD for increasing the risk of cognitive impairments. The increased risk of cognitive impairments may be due to different underlying mechanisms.

Footnotes

ACKNOWLEDGMENTS

The authors have no acknowledgments to report.

FUNDING

This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $295,903 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

CONFLICT OF INTEREST

The authors have no conflict of interest to report. Wei Li is an Editorial Board Member of this journal but was not involved in the peer-review process nor had access to any information regarding its peer review.

DATA AVAILABILITY

All data are available upon reasonable request by following the institution’s data-sharing policy.

References

World Health Organization. Global status report on alcohol and health 2018. https://www.who.int/publications/i/item/9789241565639. Retrieved on December 29, 2022.

Zuccalà

, Onder

, Pedone

, Cesari

, Landi

, Bernabei

, Cocchi

; Gruppo Italiano di Farmacoepidemiologia nell’Anziano Investigators (2001) Dose-related impact of alcohol consumption on cognitive function in advanced age: Results of a multicenter survey. Alcohol Clin Exp Res 25, 1743–1748.

SAMHSA, Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use and Health. Table 5.4A – Alcohol Use Disorder in Past Year among Persons Aged 12 or Older, by Age Group and Demographic Characteristics: Numbers in Thousands, 2018 and 2019. https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect5pe2019.htm. Accessed January 2, 2023.

Haddaway

, Pritchard

, McGuinness

(2021) PRISMA2020: R package and ShinyApp for producing PRISMA 2020 compliant flow diagrams. Zenodo, http://doi.org/10.5281/zenodo.42--87834

Almeida

, Hankey

, Yeap

, Golledge

, Flicker

(2014) Alcohol consumption and cognitive impairment in older men: A mendelian randomization study. Neurology 82, 1038–1044.

Kim

, Kim

, Park

(2016) Association between alcohol drinking behaviour and cognitive function: Results from a nationwide longitudinal study of South Korea. BMJ Open 6, e010494.

DeFranco

, Tarbox

, McLaughlin

(1985) Cognitive deficits as a function of years of alcohol abuse. Am J Drug Alcohol Abuse 11, 279–293.

Woods

, Porges

, Bryant

, Seider

, Gongvatana

, Kahler

, de la Monte

, Monti

, Cohen

(2016) Current heavy alcohol consumption is associated with greater cognitive impairment in older adults. Alcohol Clin Exp Res 40, 2435–2444.

Williams

, Skinner

(1990) The cognitive effects of alcohol abuse: A controlled study. Br J Addict 85, 911–917.

10.

Liappas

, Theotoka

, Kapaki

, Ilias

, Paraskevas

, Soldatos

(2007) Neuropsychological assessment of cognitive function in chronic alcohol-dependent patients and patients with Alzheimer’s disease. In Vivo 21, 1115–1118.

11.

Blanco-Presas

, Moreno-Alcázar

, Alonso-Lana

, Salvador

, Pomarol-Clotet

, McKenna

(2018) Cognitive impairment associated with cocaine use: The role of co-existent alcohol abuse/dependence. Drug Alcohol Depend 189, 70–75.

12.

Ros-Cucurull

, Palma-Álvarez

, Cardona-Rubira

, García-Raboso

, Jacas

, Grau-López

, Abad

, Rodríguez-Cintas

, Ros-Montalbán

, Casas

, Ramos-Quiroga

, Roncero

(2018) Alcohol use disorder and cognitive impairment in old age patients: A 6 months follow-up study in an outpatient unit in Barcelona. Psychiatry Res 261, 361–366.

13.

Villa

, Espandian

, Sáiz

, Astals

, Valencia

, Martínez-Santamaría

, Álvarez

, García-Portilla

, Bobes

, Flórez

(2021) Cognitive functioning in patients with alcohol use disorder who start outpatient treatment. Adicciones 33, 161–174.

14.

Cairney

, Clough

, Jaragba

, Maruff

(2007) Cognitive impairment in Aboriginal people with heavy episodic patterns of alcohol use. Addiction 102, 909–915.

15.

Viswam

, Nagarajan

, Kuppili

, Bharadwaj

(2018) Cognitive functions among recently detoxified patients with alcohol dependence and their association with motivational state to quit. Indian J Psychol Med 40, 310–314.

16.

Hudetz

, Warltier

(2007) Cognitive function in older diabetic subjects with a history of alcohol abuse. Psychol Rep 101, 1125–1132.

17.

Hudetz

, Iqbal

, Gandhi

, Patterson

, Hyde

, Reddy

, Hudetz

, Warltier

(2007) Postoperative cognitive dysfunction in older patients with a history of alcohol abuse. Anesthesiology 106, 423–430.

18.

Regier

, Farmer

, Rae

, Locke

, Keith

, Judd

, Goodwin

(1990) Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA 264, 2511–2518.

19.

Jett

, Kordas

, Parent

, Keshtkar

, Shin

, King

, McPherson

, Ries

, Roll

, McDonell

, Chaytor

(2023) Assessing clinically significant cognitive impairment using the NIH toolbox in individuals with co-occurring serious mental illness and alcohol use disorder. J Addict Med 17, 305–311.

20.

Manning

, Wanigaratne

, Best

, Strathdee

, Schrover

, Gossop

(2007) Screening for cognitive functioning in psychiatric outpatients with schizophrenia, alcohol dependence, and dual diagnosis. Schizophr Res 91, 151–158.

21.

Lindsay

, Hébert

, Rockwood

(1997) The Canadian study of health and aging: Risk factors for vascular dementia. Stroke 28, 526–530.

22.

Bahorik

, Bobrow

, Hoang

, Yaffe

(2021) Increased risk of dementia in older female US veterans with alcohol use disorder. Addiction 116, 2049–2055.

23.

McMurtray

, Clark

, Christine

, Mendez

(2006) Early-onset dementia: Frequency and causes compared to late-onset dementia. Dement Geriatr Cogn Disord 21, 59–64.

24.

Sabia

, Fayosse

, Dumurgier

, Dugravot

, Akbaraly

, Britton

, Kivimäki

, Singh-Manoux

(2018) Alcohol consumption and risk of dementia: 23 year follow-up of Whitehall II cohort study. BMJ 362, k2927.

25.

Schmidt

, Gallo

, Ferri

, Giovannetti

, Sestito

, Libon

, Schmidt

(2005) The neuropsychological profile of alcohol-related dementia suggests cortical and subcortical pathology. Dement Geriatr Cogn Disord 20, 286–291.

26.

Fratiglioni

, Ahlbom

, Viitanen

, Winblad

(1993) Risk factors for late-onset Alzheimer’s disease: A population-based, case-control study. Ann Neurol 33, 258–266.

27.

Broe

, Henderson

, Creasey

, McCusker

, Korten

, Jorm

, Longley

, Anthony

(1990) A case-control study of Alzheimer’s disease in Australia. Neurology 40, 1698–1707.

28.

Miller

, Orwat

, Rahimi

, Mintzer

(2019) A retrospective, population-based cohort study of driving under the influence, Alzheimer’s disease diagnosis, and survival. Int Psychogeriatr 31, 571–577.

29.

Teri

, Hughes

, Larson

(1990) Cognitive deterioration in Alzheimer’s disease: Behavioral and health factors. J Gerontol 45, 58–63.

30.

Zhornitsky

, Chaudhary

, Le

, Chen

, Zhang

, Potvin

, Chao

, van Dyck

, Li

(2021) Cognitive dysfunction and cerebral volumetric deficits in individuals with Alzheimer’s disease, alcohol use disorder, and dual diagnosis. Psychiatry Res Neuroimaging 317, 111380.

31.

Freund

, Ballinger

Jr (1988) Loss of cholinergic muscarinic receptors in the frontal cortex of alcohol abusers. Alcohol Clin Exp Res 12, 630–638.

32.

Freund

, Ballinger

Jr (1989) Loss of muscarinic cholinergic receptors from the temporal cortex of alcohol abusers. Metab Brain Dis 4, 121–141.

33.

Harper

, Kril

(1989) Patterns of neuronal loss in the cerebral cortex in chronic alcoholic patients. J Neurol Sci 92, 81–89.

34.

Tarquini

, Masullo

(1981) Cognitive impairment and chronic alcohol abuse: A neuropsychological study. Drug Alcohol Depend 8, 103–109.

35.

Katamanova

, Rukavishnikov

, Lakhman

, Shevchenko

, Denisova

(2015) [Cognitive impairment in a toxic lesion of the brain]. Zh Nevrol Psikhiatr Im S S Korsakova 115, 11–15.

36.

Clergue-Duval

, Questel

, Azuar

, Paquet

, Cognat

, Amami

, Queneau

, Dereux

, Barré

, Bellivier

, Farid

, Vorspan

(2020) Brain 18FDG-PET pattern in patients with alcohol-related cognitive impairment. Eur J Nucl Med Mol Imaging 47, 281–291.

37.

Bhat

, Gambhir

(2011) Neurocognitive impairment in alcohol-dependence syndrome cases and its response to treatment. Med J Armed Forces India 67, 117–121.

38.

Chou

, Chang

, Lin

, Chang

, Chen

, Ko

(2019) Thiamine for preventing dementia development among patients with alcohol use disorder: A nationwide population-based cohort study. Clin Nutr 38, 1269–1273.

39.

Sorrell

, Zolnikov

, Sharma

, Jinnai

(2006) Cognitive impairment in people diagnosed with end-stage liver disease evaluated for liver transplantation. Psychiatry Clin Neurosci 60, 174–181.

40.

Miller

, Gold

, Klahr

(1990) The diagnosis of alcohol and cannabis dependence (addiction) in cocaine dependence (addiction). Int J Addict 25, 735–744.

41.

Bezdicek

, Michalec

, Vaneckova

, Klempir

, Liskova

, Seidl

, Janikova

, Miovsky

, Hubacek

, Diblik

, Kuthan

, Pilin

, Kurcova

, Fenclova

, Petrik

, Navratil

, Pelclova

, Zakharov

, Ruzicka

(2017) Cognitive sequelae of methanol poisoning involve executive dysfunction and memory impairment in cross-sectional and long-term perspective. Alcohol 59, 27–35.