Wernicke-Korsakoff Syndrome

Wernicke-Korsakoff syndrome is a brain disorder involving loss of specific brain functions, due to a thiamine deficiency. The syndrome is actually a spectrum. Korsakoff´s typically develops as the Wernicke’s subsides. 

Wernicke’s Encephalopathy

Wernicke’s encephalopathy involves damage to multiple nerves in both the central nervous system (brain and spinal cord) and the peripheral nervous system (the rest of the body). It may also include symptoms caused by alcohol withdrawal. The cause is generally attributed to malnutrition, especially lack of vitamin B-1 (thiamine), which commonly accompanies habitual alcohol use or alcoholism.

Korsakoff Syndrome

Korsakoff syndrome, or Korsakoff psychosis, involves impairment of memory out of proportion to other cognitive functions. The most distinguishing symptom is confabulation (fabrication) where the person makes up detailed, believable stories about experiences or situations to cover the gaps in the memory. Korsakoff psychosis involves damage to areas of the brain involved with memory.

Minimal or moderate alcohol use and adequate nutrition reduce the risk of developing Wernicke-Korsakoff syndrome. 

Symptoms

Symptoms are-
  • Vision changes 
  • Double vision 
  • Eye movements abnormalities 
  • Eyelid drooping
  • Loss of muscle coordination 
  • Unsteady, uncoordinated walking
  • Loss of memory, can be profound 
  • Inability to form new memories 
  • Confabulation
Symptoms that indicate alcohol withdrawal may also be present or may develop.

Signs and Tests

A nutritional assessment may confirm malnourished state, serum B-1 levels may be low, pyruvate is elevated, and transketolase activity is decreased.
A cranial MRI rarely shows changes in the tissue of the brain indicating Wernicke-Korsakoff syndrome.

Treatment

The goals of treatment are to control symptoms as much as possible and to prevent progression of the disorder. Hospitalization is required for initial control of symptoms.

Thiamine (vitamin B-1) may improve symptoms of confusion or delirium, difficulties with vision and eye movement, and muscle incoordination. B-1 may be given by injection into a vein or a muscle, or by mouth. Thiamine does not generally improve loss of memory and intellect associated with Korsakoff psychosis.

Total abstinence from alcohol is required to prevent progressive loss of brain function and damage to peripheral nerves. A well-balanced, nourishing diet is recommended. 

Support Groups 

The stress of illness can often be helped by joining a support group where members share common experiences and problems.

The following resources provide information, support, and help on alcoholism: 

SAMSHA Substance Abuse Treatment Facility Locator
http://findtreatment.samhsa.gov/

The National Clearinghouse for Alcohol and Drug Information
http://www.health.org/links/

Alcoholics Anonymous
www.alcoholics-anonymous.org

Al-Anon/Alateen
www.al-anon.org

Many people with alcohol problems don’t recognize when their drinking gets out of hand.  In the past, treatment providers believed that alcoholics should be “confronted” about “denial” of their drinking problems, but now research has shown that compassionate and empathetic counseling is more effective.

Three general steps are involved in treating the alcoholic once the disorder has been diagnosed:  intervention, detoxification, and rehabilitation.  Research finds that the traditional confrontational intervention where family members or the employer surprises the alcoholic and threaten consequences if treatment is not begun is ‘not’ effective.  Studies find that more people enter treatment if their family members or employers are honest with them about their concerns and gradually help them to see for themselves that drinking is a problem by showing how it is preventing them from reaching their own goals.

Once the problem has been recognized, total abstinence from alcohol is required for those who are dependent. Because alcoholism affects the people closely related to the alcoholic person, treatment for family members through counseling is often necessary. 

Detoxification Is the First Phase of Treatment

Alcohol is withdrawn under a controlled, supervised setting. Tranquilizers and sedatives are often prescribed to control alcohol withdrawal symptoms. Detoxification usually takes 4 to 7 days. Examination for other medical problems is necessary, for example, liver and blood clotting problems are common. A balanced diet with vitamin supplements is important. Complications associated with the acute withdrawal of alcohol may occur, such as delirium tremors (DTs),which could be fatal. Depression or other underlying mood disorders should be treated. 

Alcohol Recovery or Rehabilitation Programs

They support the affected person after detoxification to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centers are recovering alcoholics who serve as role models. Programs can be either inpatient, with the patient residing in the facility during the treatment, or outpatient, with the patient attending the program while they reside at home.

Medications

Medicines are sometimes prescribed to prevent relapses. Naltrexone (an opioid antagonist) decreases alcohol cravings. Disulfiram (Antabuse) works by producing very unpleasant side effects if even a small amount of alcohol is ingested within 2 weeks after taking the drug. These medications are not given if the person has certain medical conditions. Long-term treatment with counseling or support groups is often necessary. The effectiveness of medication and counseling varies.

The goal of treatment for dementia and cognitive disabilities is to control the symptoms. Hospitalization may be required for a short time.
Stopping or changing medications that worsen confusion, or that are not essential to the care of the person, may improve cognitive function. Medications that contribute to confusion include anticholinergics, analgesics, cimetidine, central nervous system depressants, lidocaine, and other medications.

Disorders that contribute to confusion should be treated. These include heart failure, decreased oxygen (hypoxia), thyroid disorders, anemia, nutritional disorders, infections, and psychiatric conditions such as depression. Correction of coexisting medical and psychiatric disorders often greatly improves mental functioning.

Medications may be required to control aggressive or agitated behaviors or behaviors that are dangerous to the person or to others. These are usually given in very low doses, with adjustment as required.

Medications that may be considered for use include:
 
  • Anti-psychotics 
  • Serotonin-affecting drugs( trazodone, buspirone) 
  • Dopamine blockers (such as haloperidol, risperidol, olanzapine, clozapine)  
  • Fluoxetine, imipramine, celexa may help to stabilize mood  
  • Vitamin E
Sensory function should be evaluated and augmented as needed by the use of hearing aids, glasses, or cataract surgery.

Formal psychiatric treatment (psychotherapy, group discussions, etc.) is seldom effective because it may overload limited cognitive resources in the person with dementia.

Long Term Treatment

The provision of a safe environment, control of aggressive or agitated behavior, and the ability to meet physiologic needs may require monitoring and assistance in the home or in an institutionalized setting. This may include in-home care, boarding homes, adult day care, or convalescent homes.

Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful in caring.

In any care setting, there should be familiar objects and people. Lights that are left on at night may reduce disorientation. The schedule of activities should be simple. Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation. Family counseling may help in coping with the changes required for home care.

Alcoholics Anonymous is a self-help group of recovering alcoholics that offers emotional support and an effective model of abstinence for people recovering from alcohol dependence. There are more than 1 million members worldwide, and local chapters are found throughout the United States. 

Al-Anon is a support group for spouses and others who are affected by someone else’s alcoholism. Alateen provides support for teenage children of alcoholics. 

For those who don’t like the twelve-step approach, there are several other support groups available.  It is important that people dealing with alcohol problems know about these other groups because in the past, those who did not find AA helpful or were troubled by its requirement of submission to a “Higher Power” had no alternatives.

SMART recovery uses research-based cognitive techniques to help alcoholics recover.  LifeRing recovery and SOS are two other secular programs.  Moderation Management is a program for problem drinkers seeking to moderate their drinking– it recommends abstinence for those who fail at such attempts.  

Support Groups 

Members of AA have help available 24 hours a day, associate with a sober peer group, learn that it is possible to participate in social functions without drinking, and are given a model of recovery by observing the accomplishments of sober members of the group.  Other support groups are smaller, but growing and all have an online presence which provides support even at home late at night.  

Prognosis

Without treatment, Wernicke-Korsakoff syndrome progresses steadily to death. With treatment, symptoms such as incoordination and vision difficulties may be controlled, and progression of the disorder may be slowed or stopped. 

Some of the symptoms (particularly the loss of memory and cognitive skills) may be permanent. There may be a need for custodial care if the loss of cognitive skills is severe. Other disorders related to the abuse of alcohol may also be present.

Complications

  • Permanent loss of memory. 
  • Permanent loss of cognitive skills. 
  • Injury caused by falls. 
  • Difficulty with personal or social interaction. 
  • Alcohol withdrawal state. 
  • Permanent alcoholic neuropathy. 
  • Shortened life span. 
  • Wernicke’s encephalopathy may be precipitated in at-risk people by carbohydrate loading or glucose infusion. Supplementation with thiamine must precede glucose infusion to prevent this.
Call your health care provider if symptoms worsen or reappear. Also call if new symptoms develop, including symptoms of alcohol withdrawal: 
  • Delirium or confusion 
  • Agitation 
  • Jumpiness or nervousness 
  • Insomnia 
  • Hallucinations 
  • Palpitations 
  • Heart rate that is faster than normal without an observable cause 
  • Pale skin 
  • Profuse sweating 
  • Muscle tremors 
  • Seizures 
  • Headache 
  • Fever 
  • Nausea/vomiting