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Recognising cognitive impairment

There are several domains of cognitive functioning, such as attention and memory, and each of these can be selectively or jointly impaired.

What is cognitive impairment?

Cognitive functioning or cognition refers to the processing of information by the brain, and can be described as a person's ability to think, concentrate, formulate ideas, reason and remember (Gray, Forell & Clarke 2009).

There are several domains of cognitive functioning, including:

  • Attention
  • Memory
  • Visuo-spatial skills (which allow us to visually perceive objects and the spatial relationships among them), and
  • Executive functioning (which includes tasks that help people learn new information, remember and retrieve information, plan, make decisions, and use information to solve problems).

Each of these domains can be selectively or jointly impaired across a range of developmental, neurological, acquired brain injury, mental illness, substance-related or dementia conditions. The term 'cognitive impairment' is used to recognise a broad range of disorders that affect cognitive functioning. Cognitive impairment may be 'hidden' from a worker when a person first enters a program, especially if the person has a mild impairment. Common causes of cognitive impairment are listed in the following table.

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Common causes

Developmental Fetal alcohol syndrome and related disorders

Learning disorder

Attention deficit hyperactivity disorder

Autistic disorder/Asperger's disorder

Intellectual disability
Acquired brain injury Traumatic brain injury


Hypoxic brain injury

Alcohol and other drug-related brain injury
Neurological Multiple sclerosis

Huntington's disease

Parkinson's disease
Mental illness Depression/anxiety

Dementia Alzheimer's dementia

Vascular dementia

Fronto-temporal dementia

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Common indicators

The indicators of a person with cognitive impairment are highly varied. They may have difficulties engaging with other people or services, identifying and maintaining suitable work or study, driving a car, carrying out daily activities (e.g. paying bills) or managing basic aspects of self-care. Cognitive impairment rarely occurs in isolation, i.e. without affecting both emotional and behavioural functioning. In fact, behavioural and emotional disturbances often reveal the presence of cognitive impairment.

Addressing cognitive impairment through compensatory or remedial approaches may reduce challenging behaviour and emotional distress. Some people lack the knowledge or resources to cope with their cognitive, behavioural and/or emotional difficulties and use alcohol or other drugs to cope, which often further impairs functioning in these domains. All three factors - cognition (thinking), behaviour (acting) and emotions (feeling) - affect a person's ability to get by in the world.

Neuropsychological Cognitive Behavioural Model

Neuro CBT Model

Source: Adapted from Berry (2012).

At a broad level, people with cognitive impairment will experience difficulties with adaptive behaviours. These include social, conceptual and practical skills they have learned in order to function in their daily lives (The Arc 2011).

A person with impaired conceptual skills, for example, receptive and expressive language, reading and writing, money concepts and self-direction may present with:

  • A low literacy level
  • Comprehension difficulties, including with abstract concepts and complex instructions
  • Problems planning and organising daily activities
  • Problems with budgeting and managing money.

A person with impaired social skills, for example, relating to other people and the external social environment, as well as self-esteem, personal sense of responsibility may:

  • Have difficulties following rules (including laws)
  • Respond inappropriately in some social settings
  • Have low self-esteem
  • Be vulnerable to victimisation.

A person with impaired practical skills, for example, personal daily activities such as eating, dressing and mobility may have difficulties with:

  • Preparing meals
  • Using transport
  • Using the telephone
  • Maintaining a safe living environment.
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Hiding, masking or denying disability

Cognitive impairment is often masked. For most people who come into contact with drug and alcohol services, their cognitive impairment is in no way visible. It's only through observing their behaviour in the assessment process or while they're receiving treatment that we may get clues that they may have a cognitive impairment.

Many people with cognitive impairment are very good at hiding their disability. This may be because they want to fit in with everyone else or because they might be very high functioning in some areas of their lives or have very good expressive communication yet have very poor receptive communication. Also, people will have typically experienced discrimination, shame and humiliation as a consequence of being labelled due to their disability. Often if a person is aware they have a cognitive impairment, they won't readily admit to it.

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What does this mean for your service?

Having a cognitive disability can often result in a person not being able to access or maintain the drug and alcohol treatment they require. People with a cognitive impairment often:

  • Don't receive the services they need
  • Are unable to maintain waiting list protocols
  • Fall through services gaps and experience a referral merry-go-round
  • Are screened out of entry to services
  • Are perceived to have no or low motivation
  • Are put in the 'too hard basket'
  • Are said to have challenging/problem behaviours when they in fact have a cognitive impairment
  • Are exited from services early
  • Are unable to access services because they don't have a diagnosis
  • Are told that disability services should address their drug and alcohol issues.

When armed with the knowledge of how cognitive impairment can affect a person and the practical strategies to support a person combined with some adjustments in service provision, drug and alcohol services can successfully support people with intellectual disability, acquired brain injury and fetal alcohol spectrum disorder to receive the expert drug and alcohol treatment they need.

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Find out more

For more information on strategies for working better with people with cognitive impairment see Practice Tips for Workers.