Wernicke -Korsakoff Syndrome

Clinical Description

Is characterized by confusion, ataxia and ocular disturbances (usually due to weakness or paralysis of 6th cranial nerve) including nystagmus

• May have acute onset or develop slowly over 1 week or so
• Korsakoff's psychosis is a state of amnesia that usually follows Wernicke’s syndrome
• This is due to thiamine (vitamin B1) deficiency in alcoholics and malnourished non- alcoholics

Signs and Symptoms

• Mostly anterograde amnesia (inability to retain new memories) and possibly retrograde amnesia (inability to recall the past)
• Fabricating answers or confabulating to cover their memory problems, and
• Oculomotor disturbances - nystagmus.
• Patient is alert but can be confused if having Wernicke’s disease, responsive and normal

Investigations

• Substance use history
• String test to diagnose Korsakoff's psychosis (clinician asks the patient to take an imaginary string in his or her hands, and the patient complies, as though the string were real)
• Do a physical examination to rule out medical complications or comorbid illnesses
• Laboratory tests include FBC, offer PITC for HIV, LFTs, Urine/ Blood glucose test

Non-pharmacological

Management of Physical and Neurological

Complications of Alcohol Dependence

• Conduct a comprehensive physical examination of the patient
• Counsel the patient
• Institute a brief intervention or motivational interview
• Abstinence is essential
• Refer to Alcoholic Anonymous groups if available or link with other agencies such as religious organizations, social welfare services
• Encourage a healthy diet with high protein and vitamin content (give thiamine or Vitamin B Complex)
• Treat specific disorders symptomatically
• (e.g., gastro-intestinal disorders, cirrhosis, neuropathy) as per guidelines

Pharmacological

The aim is to rapidly treat Wernicke's syndrome in order to prevent onset of Korsakoff's psychosis

• Immediately give Thiamine (Vitamin B1) 500 mg IV over 30 minutes 8 hourly for 2 consecutive days followed by 250mg IV/IM 24 hourly for 5 days follow with one month of oral thiamine 100mg OD
• Glucose without Vitamin B1 can worsen Wernicke's encephalopathy
• Advise the patient to abstain from alcohol use or consider alcohol detoxification to prevent alcohol withdrawal
• Always treat medical complications of chronic alcohol use such as GIT, neurologic, cardiovascular, pulmonary, hematologic and endocrine.
• To treat delirium tremens: see alcohol withdrawal section

Red Flags

For Admission

• If delirium tremens or wernickes encephalopathy
• Severe medical complications of chronic alcohol use such as vomiting blood
• Continued high risk alcohol use or multiple substance use

Follow-up

• Assess for continued alcohol use and offer brief intervention to promote change in alcohol use on each visit
• Assess for and treat the medical complications
• Counsel the patient using problem solving technique
• Educate and support the family