Medicine:Alcoholic Korsakoff syndrome

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Alcoholic Korsakoff syndrome
Other namesKorsakoff syndrome, Korsakov syndrome, Alcohol amnestic disorder

Alcoholic Korsakoff syndrome (AKS), Korsakoff syndrome[1] is an amnestic disorder caused by thiamine (vitamin B1) deficiency associated with prolonged ingestion of alcohol. There is a similar condition seen in non-alcoholic Korsakoff syndrome. This neurological disorder is caused by a lack of thiamine in the brain, and is also exacerbated by the neurotoxic effects of alcohol. When Wernicke encephalopathy accompanies alcoholic Korsakoff syndrome the combination is called Wernicke–Korsakoff syndrome; however, a recognized episode of Wernicke encephalopathy is not always obvious. The syndrome and psychosis are named after Sergei Korsakoff, a Russian neuropsychiatrist who discovered the syndrome during the late 19th century.

Signs and symptoms

There are seven major symptoms of alcoholic Korsakoff syndrome (amnestic-confabulatory syndrome):

  1. anterograde amnesia, memory loss for events after the onset of the syndrome
  2. retrograde amnesia, memory loss extends back for some time before the onset of the syndrome
  3. amnesia of fixation, also known as fixation amnesia (loss of immediate memory, a person being unable to remember events of the past few minutes)[2][3][4]
  4. confabulation, that is, invented memories which are then taken by the patient as true due to gaps in memory, with such gaps sometimes associated with blackouts
  5. minimal content in conversation
  6. lack of insight
  7. apathy – the patients lose interest in things quickly, and generally appear indifferent to change.

Benon R. and LeHuché R. (1920) described the characteristic signs of alcoholic Korsakoff syndrome with some additional features including: confabulation (false memories), fixation amnesia, paragnosia or false recognition of places, mental excitation, and euphoria.[5]

Thiamine is essential for the decarboxylation of pyruvate, and deficiency during this metabolic process is thought to cause damage to the medial thalamus and mammillary bodies of the posterior hypothalamus, as well as generalized cerebral atrophy.[6] These brain regions are all parts of the limbic system, which is heavily involved in emotion and memory.

AKS involves neuronal loss, that is, damage to neurons; gliosis, which is a result of damage to supporting cells of the central nervous system, and hemorrhage or bleeding also occurs in mammillary bodies. Damage to the dorsomedial nucleus or anterior group of the thalamus (limbic-specific nuclei) is also associated with this disorder. Cortical dysfunction may have arisen from thiamine deficiency, alcohol neurotoxicity, and/or structural damage in the diencephalon.[7]

Originally, it was thought that a lack of initiative and a flat affect were important characteristics of emotional presentation in sufferers. Studies have questioned this, proposing that neither is necessarily a symptom of AKS. Research suggesting that Korsakoff patients are emotionally unimpaired has made this a controversial topic. It can be argued that apathy, which usually characterizes Korsakoff patients, reflects a deficit of emotional expressions, without affecting the experience or perception of emotion.[8]

AKS causes deficits in declarative memory in most patients,[9] but leaves implicit spatial, verbal, and procedural memory functioning intact.[10] People with AKS have deficits in the processing of contextual information. Context memories refers to the where and when of experiences, and is an essential part of recollection. The ability to store and retrieve this information, such as spatial location or temporal order information, is impaired.[11] Research has also suggested that Korsakoff patients have impaired executive functions, which can lead to behavioral problems and interfere with daily activities. It is unclear, however, which executive functions are affected most.[12] Nonetheless, IQ is usually not affected by the brain damage associated with Korsakoff's syndrome.[13]

At first it was thought that AKS patients used confabulation to fill in memory gaps. However, it has been found that confabulation and amnesia do not necessarily co-occur. Studies have shown that there is dissociation between provoked confabulation, spontaneous confabulation (which is unprovoked), and false memories.[9] That is, patients could be led to believe certain things had happened which actually had not, but so could people without alcoholic Korsakoff syndrome.

Causes

Conditions resulting in thiamine deficiency and its effects include chronic alcoholism and severe malnutrition.[14] Alcoholism may co-occur with poor nutrition, which in addition to inflammation of the stomach lining, causes thiamine deficiency.[15] Other causes include dietary deficiencies, prolonged vomiting, eating disorders, and the effects of chemotherapy. It can also occur in pregnant women who have a form of extreme morning sickness known as hyperemesis gravidarum.[16] Mercury poisoning can also lead to Korsakoff's syndrome.[17] Though it does not always co-occur, this disorder can emerge frequently as a consequential result of Wernicke's encephalopathy.[18]

PET scans show that there is a decrease of glucose metabolism in the frontal, parietal and cingulated regions of the brain in Korsakoff's patients. This may contribute to memory loss and amnesia. Structural neuroimaging has also shown the presence of midline diencephalic lesions and cortical atrophy.[7]

Structural lesions of the central nervous system, though rare, can also contribute to symptoms of AKS. Severe damage to the medial dorsal nucleus inevitably results in memory deficit. Additionally, autopsies of patients with AKS have showed lesions in both the midline and anterior thalamus, and thalamic infarctions. Bilateral infarctions to the thalamus can result in Korsakoff-induced amnesia as well. These findings imply damage to anterior thalamic nuclei can result in disruptive memory.[19][20]

Risk factors

A number of factors may increase a person's risk to develop alcoholic Korsakoff syndrome. These factors are often related to patients’ general health and their food intake habits.[21]

  • Age
  • Alcoholism
  • Chemotherapy
  • Dialysis
  • Extreme dieting
  • Genetic factors

The prevalence varies from country to country, but is estimated to be around 12.5% of heavy drinkers.[22]

Diagnosis

AKS is primarily a clinical diagnosis, imaging and lab tests are not necessary.

Treatment

It was once assumed that anyone suffering from AKS would eventually need full-time care. This is still often the case, but rehabilitation can help regain some, albeit often limited, level of independence.[20] Treatment involves the replacement or supplementation of thiamine by intravenous (IV) or intramuscular (IM) injection, together with proper nutrition and hydration. However, the amnesia and brain damage caused by the disease does not always respond to thiamine replacement therapy. In some cases, drug therapy is recommended. Treatment of the patient typically requires taking thiamine orally for 3 to 12 months, though only about 20 percent of cases are reversible. If treatment is successful, improvement will become apparent within two years, although recovery is slow and often incomplete.

As an immediate form of treatment, a pairing of IV or IM thiamine with a high concentration of B-complex vitamins can be administered three times daily for period of 2–3 days. In most cases, an effective response from patients will be observed. A dose of 1 gram of thiamine can also be administered to achieve a clinical response.[23] In patients who are seriously malnourished, the sudden availability of glucose without proper bodily levels of thiamine to metabolize is thought to cause damage to cells. Thus, the administration of thiamine along with an intravenous form of glucose is often good practice.[24]

Treatment for the memory aspect of AKS can also include domain-specific learning, which when used for rehabilitation is called the method of vanishing cues. Such treatments aim to use patients' intact memory processes as the basis for rehabilitation. Patients who used the method of vanishing cues in therapy were found to learn and retain information more easily.[25]

People diagnosed with AKS are reported to have a normal life expectancy, presuming that they abstain from alcohol and follow a balanced diet. Empirical research has suggested that good health practices have beneficial effects in alcoholic Korsakoff syndrome.[24]

Prevention

The most effective method of preventing AKS is to avoid B vitamin/thiamine deficiency. In Western nations, the most common causes of such a deficiency are alcoholism and eating disorders.[20] Because these are behavioral-induced causes, alcoholic Korsakoff syndrome is essentially considered a preventable disease. Thus, fortifying foods with thiamine, or requiring companies that sell alcoholic beverages to supplement them with B vitamins in general or thiamine in particular, could avert many cases of AKS.[26][27]

Case studies

In a case of a non-alcoholic 63-year-old man with severe right hippocampal hemorrhage, neuropsychological assessments showed that he displayed severe anterograde amnesia, loss of recall, impaired recognition, and overall disorientation. He knew his birthday and could recall genuine memories of his childhood, but consistently asked about his parents who had died 25 years earlier. Thalamic damage is thought to have been the trigger for the amnestic syndrome.[19]

See also

References

  1. ↑ "Alcoholic Korsakoff Syndrome - MeSH - NCBI". https://www.ncbi.nlm.nih.gov/mesh/2023500. 
  2. ↑ Nyssen R. (1960). "[Study of "amnesia of fixation" in Korsakoff's disease by non-repeated acquisition tests]." (in French). Acta neurologica et psychiatrica Belgica 60: 783–793. PMID 13730001. 
  3. ↑ Nyssen R. (1957). "[Experimental contribution to the study of fixation amnesia in Korsakoff's syndrome of alcoholic origin]." (in French). Acta neurologica et psychiatrica Belgica 57 (8): 839–66. PMID 13478443. 
  4. ↑ C. W. M. Whitty; O. L. Zangwill (22 October 2013). Amnesia: Clinical, Psychological and Medicolegal Aspects. Elsevier Science. pp. 76. ISBN 978-1-4831-6514-1. https://books.google.com/books?id=qOZFBQAAQBAJ&pg=PA76. 
  5. ↑ Benon R., LeHuché R. (1920). "Cranial Injuries and Korsakoff's Psychosis" (in French). Archives Suisses de Neurologie, Neurochirurgie et Psychiatrie: 319. 
  6. ↑ Kolb, Bryan; Whishaw, Ian Q. (2003). Fundamentals of human neuropsychology. New York: Worth Publishers. p. 473. ISBN 978-0-7167-5300-1. OCLC 55617319. 
  7. ↑ 7.0 7.1 Paller, K. A.; Acharya, A.; Richardson, Brian C.; Plaisant, Odile; Shimamura, Arthur P.; Reed, Bruce R.; Jagust, William J. (1997). "Functional neuroimaging of cortical dysfunction in alcoholic Korsakoff's syndrome". Journal of Cognitive Neuroscience 9 (2): 277–293. doi:10.1162/jocn.1997.9.2.277. 
  8. ↑ Doulas, J.; Wilkinson, D. A. (1993). "Evidence of normal emotional responsiveness in alcoholic Korsakoff's syndrome in the presence of profound memory impairment". Addiction 88 (12): 1637–1645. doi:10.1111/j.1360-0443.1993.tb02038.x. PMID 8130702. 
  9. ↑ 9.0 9.1 Kessels, Roy P. C.; Kortrijk, Hans E.; Wester, Arie J.; Nys, Gudrun M. S. (1 April 2008). "Confabulation behavior and false memories in Korsakoff's syndrome: Role of source memory and executive functioning". Psychiatry and Clinical Neurosciences 62 (2): 220–225. doi:10.1111/j.1440-1819.2008.01758.x. PMID 18412846. 
  10. ↑ Oudman, Erik; Van Der Stigchel, Stefan; Wester, Arie J.; Kessels, Roy P.C.; Postma, Albert (2011). "Intact memory for implicit contextual information in Korsakoff's amnesia". Neuropsychologia 49 (10): 2848–2855. doi:10.1016/j.neuropsychologia.2011.06.010. PMID 21704050. 
  11. ↑ Parkin A. J.; Montaldi D.; Leng N. R.; Hunkin N. M. (1999). "Contextual cueing effects in the remote memory of alcoholic Korsakoff patients and normal subjects". The Quarterly Journal of Experimental Psychology 42A: 585–596. doi:10.1080/14640749008401238. 
  12. ↑ Kessels, R. P. C.; Van Oort, R. (2009). "Executive dysfunction in Korsakoff's syndrome: time to revise the DSM criteria for alcohol-induced persisting amnestic disorder?". International Journal of Psychiatry in Clinical Practice 13 (1): 78–81. doi:10.1080/13651500802308290. 
  13. ↑ Oscar-Berman, M. (Jun 2012). "Function and dysfunction of prefrontal brain circuitry in alcoholic Korsakoff's syndrome.". Neuropsychol Rev 22 (2): 154–69. doi:10.1007/s11065-012-9198-x. PMID 22538385. 
  14. ↑ Carlson, Neil; Birkett, Melissa (2017). Physiology of Behavior. Pearson. pp. 514. ISBN 0-13-408091-2. 
  15. ↑ "What is Korsakoff’s syndrome?". Alzheimer's Society. October 2008. http://www.alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200171&documentID=98. 
  16. ↑ Jasmin, Luc (13 February 2008). "Wernicke-Korsakoff syndrome". MedlinePlus Medical Encyclopedia. United States National Library of Medicine. https://www.nlm.nih.gov/medlineplus/ency/article/000771.htm. Retrieved 16 July 2009. 
  17. ↑ ATSDR. 1999. Toxicological Profile for Mercury. Atlanta, GA:Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc.gov/toxprofiles/tp46.pdf
  18. ↑ Pitel A. L.; Zahr N. M.; Jackson K.; Sassoon S. A.; Rosenbloom M. J.; Pfefferbaum A.; Sullivan E. V. (2011). "Signs of preclinical Wernicke's encephalopathy and thiamine levels as predictors of neuropsychological deficits in alcoholism without Korsakoff's syndrome". Neuropsychopharmacology 36: 580–588. doi:10.1038/npp.2010.189. PMID 20962766. 
  19. ↑ 19.0 19.1 Rahme, R; Moussa, R; Awada, A; Ibrahim, I; Ali, Y; Maarrawi, J; Rizk, T; Nohra, G et al. (April 2007). "Acute Korsakoff-like amnestic syndrome resulting from left thalamic infarction following a right hippocampal hemorrhage". AJNR. American journal of neuroradiology 28 (4): 759–60. PMID 17416834. 
  20. ↑ 20.0 20.1 20.2 Kopelman, MD; Thomson, AD; Guerrini, I; Marshall, EJ (Mar–Apr 2009). "The Korsakoff syndrome: clinical aspects, psychology and treatment". Alcohol and Alcoholism 44 (2): 148–54. doi:10.1093/alcalc/agn118. PMID 19151162. 
  21. ↑ Rosenblum, Laurie B. (March 2011). "Korsakoff's Syndrome". NYU Langone Medical Center. Archived from the original. Error: If you specify |archiveurl=, you must also specify |archivedate=. https://web.archive.org/web/20120426200305/http://psych.med.nyu.edu/conditions-we-treat/conditions/korsakoffs-syndrome. Retrieved February 12, 2012. 
  22. ↑ Harper, C; Gold, J; Rodriguez, M; Perdices, M (1 February 1989). "The prevalence of the Wernicke-Korsakoff syndrome in Sydney, Australia: a prospective necropsy study". Journal of Neurology, Neurosurgery & Psychiatry 52 (2): 282–285. doi:10.1136/jnnp.52.2.282. 
  23. ↑ Carlson, N. R. (2013). Physiology of behavior. Boston: Pearson. 547.
  24. ↑ 24.0 24.1 Cook, CC (May–Jun 2000). "Prevention and treatment of Wernicke-Korsakoff syndrome". Alcohol and Alcoholism Supplement 35 (1): 19–20. doi:10.1093/alcalc/35.Supplement_1.19. PMID 11304070. 
  25. ↑ Komatsu, Shin-Ichi; Mimura, Masaru; Kato, Motoichiro; Wakamatsu, Naoki; Kashima, Haruo (1 March 2000). "Errorless and Effortful Processes Involved in the Learning of Face-name Associations by Patients with Alcoholic Korsakoff's Syndrome". Neuropsychological Rehabilitation 10 (2): 113–132. doi:10.1080/096020100389200. 
  26. ↑ Harper, CG; Sheedy, DL; Lara, AI; Garrick, TM; Hilton, JM; Raisanen, J (Jun 1, 1998). "Prevalence of Wernicke-Korsakoff syndrome in Australia: has thiamine fortification made a difference?". The Medical Journal of Australia 168 (11): 542–5. PMID 9640303. 
  27. ↑ Centerwall, BS; Criqui, MH (1978). "Prevention of the Wernicke-Korsakoff syndrome: a cost-benefit analysis". New England Journal of Medicine 299: 285–9. doi:10.1056/nejm197808102990605. PMID 96343. 

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