WERNICKE KORSAKOFF SYNDROME

Michelle Horsfall Care Home Educator Bradford and Airedale Teaching PCT
September 2006. Review date Sept 2007

AIMS & OBJECTIVES

Aims To provide an understanding of Wernicke-Korsakoffs syndrome To promote effective care for patients with Korsakoff syndrome Objectives Participants will: Discuss the impacts of regular heavy drinking Determine what Wernickes encephalopathy is Determine what Korsakoff syndrome is Discuss the permanent effects of Korsakoff syndrome Discuss management in a care home setting

IMPACTS OF REGULAR HEAVY DRINKING

REGULAR HEAVY DRINKER

SOCIAL

PSYCHOLOGICAL

PHYSICAL

Family problems, Divorce, Homelessness, Work difficulties, Unemployment, Financial difficulties, Fraud, Debt, Convictions for drunkenness, Vagrancy

Insomnia, Depression, Anxiety, Attempted suicide, Changes in personality, Amnesia, Delirium Tremens, Withdrawal fits, Dementia, Gambling, Hallucinations, Misuse of other drugs

Fatty liver, Hepatitis, Cirrhosis, Liver cancer, Pancreatitis, Cancer of mouth, larynx, oesophagus, Nutritional deficiencies, Obesity, Diabetes, Cardiomyopathy, Hypertension, Stroke, Brain damage, Neuropathy, Sexual dysfunction and infertility, Reactions with other drugs

BACKGROUND
One in four acute male admissions is alcohol related Alcohol costs the NHS up to 3 billion a year (Royal College of Physicians) 8 out of 10 people attending A/E at peak times receive treatment for alcohol related injuries compared with 1 in 6 during normal hours (HEA 1998) A recent study found 21% of psychiatric admissions over a six month period were alcohol related (CMO 2001)

BACKGROUND
Alcohol misuse is implicated in 40% of violent crimes 39% of deaths in fires 15% of drownings 1 in 6 road traffic deaths (Alcohol Concern Fact sheet (Health Impacts of Alcohol)

WHAT IS WERNICKE KORSAKOFF SYNDROME?

A form of brain damage associated with alcohol misuse. The syndrome is made up of two separate but related disorders, Wernickes encephalopathy and Korsakoffs psychosis (Alcohol Concern 2001)

WERNICKES ENCEPHALOPATHY
First described by Carl Wernicke in 1881 Caused by a lack of thiamine (vitamin B1) Evidence on post mortem in about 2 % of the population and 12.5% of dependent drinkers Fatal in 17 -20% of cases 85% of survivors go on to develop Korsakoff psychosis Affects people in their 30s, 40s and 50s as well as older people A quarter of these will require long term residential care

(1848 1905)

SYMPTOMS OF WERNICKES ENCEPHALOPATHY

Confusion about time and place Drowsiness Poor balance Double vision Abnormal eye movements or paralysis of eye muscles that might seem like a squint

THIAMINE DEFICEINCY
Increased alcohol consumption Poor dietary intake Stomach or liver damage

What is the importance of Thiamine? Metabolizes glucose to produce energy in the brain. Lack of it affects Hypothalamus: Regulates body temperature, growth and appetite, and emotional response. Controls pituitary functions including metabolism and hormones. Mammillary Bodies: Neural pathways connect various parts of the brain involved in memory function. Frontal lobe: impulse control, judgment, language, memory, motor function, problem solving, socialization and spontaneity. The Frontal lobes assist in planning, coordinating, controlling and executing behaviour.

TREATMENT OF WERNICKES
Large doses of Thiamine given IV or IM

Wernicke-Korsakoffs Syndrome
Thiamine (vitamin B1) food sources:
1. 2. 3. 4. 5. 6. 7. 8. 9. Dried yeast Most vegetables Rice husks Bran Oatmeal Milk Peanuts Liver Pork

SERGEI KORSAKOFF (1853 1900)

KORSAKOFF SYNDROME
Most commonly seen as an enduring complication of alcohol dependence Classically an amnesic syndrome with impaired recent memory and relatively intact intellectual function

KORSAKOFF SYNDROME
Loss of memory particularly STM loss Loss of spontaneity and initiative Confabulation

CONFABULATION
Spontaneous confabulation Provoked confabulation

MEMORY LOSS
More commonly STM loss Anterogade amnesia Episode of Wernickes encephalopathy may be cut off point

LOSS OF SPONTINAIETY AND INITIATIVE

Conversation

OTHER IMPAIRMENTS
Unable to gauge the passing of time and when events have occurred Cognitive impairment Easily distracted and unable to screen out relevant information Skills learned before cut off point may be unaffected

ARE THE EFFECTS PERMENANT

PROGNOSIS WITH REHABILITATION (CASE STUDIES)

44 patients allocated to nursing homes or specialist Korsakoff accommodation Nursing home patients showed more deterioration in social functioning compared to those allocated to specialist accommodation Cognitive functioning was equal in both groups (Blansjaar et al 1992)

PROGNOSIS WITH REHABILITATION (CASE STUDIES)

Dedicated in-patient service in Sydney, Australia 104 patients (93 man and 11 women) underwent a structured rehabilitation programme 51% were successfully placed in the community at follow up 1 2 years after leaving hospital (Lennane, 1986)

PROGNOSIS WITH REHABILITATION (CASE STUDIES)

Of the 53 patients who were successfully placed, the majority were living in boarding houses with supply of meals and a degree of supervision

PROGNOSIS
Not progressive in the way that an organic cause of dementia, e.g., Alzheimer's is Success of treatment will depend on the degree of damage done to the brain

MANAGEMENT IN A CARE HOME SETTING

Lots of visual clues E.g. Notices Photographs (from outings, events, holidays) Effective alcohol policies

GENERAL HEALTH
Diet Medications (supervised) General health Oral health Personal care

CONSISTENCY
The more consistency the better As little change as possible to routine Be prescriptive

REPLACING PREVIOUS LIFESTYLE

In house activities every day Encourage involvement in domestic activities Quiz groups Drama groups Outings Holidays

FAMILY
Maintain family contact if possible No mobile phones Money management Communication with family members

Any questions?

RESOURCES
Institute of Alcohol Studies (2006) Alcohol and Health St. Ives, IAS Institute of Alcohol Studies (1999) Alcohol and the Elderly St. Ives, IAS Alcohol Concern Fact sheet 17: Alcohol and Mental Health Bridges. K et al (1999) Alcohol related thiamine deficiency and malnutrition Critical Care Nurse 19(6)80 Alzheimers Society (2003) Facts about dementia: What is Korsakoffs Syndrome London, Alzheimers Society Memory function; There is hope for alcoholics with Korsakoff Syndrome (2006) Available at http://www.brightsurf.com/search/ra/Korsakoff/1/Korsakoff_news.html

RESOURCES Cont;
Alcohol Concern (2001) Fact sheet 6 summary Wernicke-Korsakoffs syndrome London, Alcohol Concern Jernigan. T, Ostergaad. A (1995) When alcoholism affects memory functions Alcohol and Research World 19(2)104 Korsakoffs Syndrome Available at http://www.patient.co.uk/showdoc/40001248/ Robinson. K (2003) Wernickes Encephalopathy Emergency Nurse 11(5)30 Alcohol Concern (2002) Acquire Alcohol Concerns quarterly information and research bulletin London, Alcohol Concern

ACKNOWLEDGEMENTS
This session has been endorsed by Dr. Anne Cahill, Consultant, Drugs and Alcohol Service, Bradford District Care Trust