Acquisition of an instrumental activity of daily living in patients with Korsakoff's syndrome: a comparison of trial and error and errorless learning

Cognitive impairment among alcohol treatment service users in South Wales: an exploratory examination of typologies of behaviour, impairment, and service attendance

Introduction

Alcohol dependence is a global issue with many negative consequences, including alcohol-related brain damage (ARBD). Assessment of the sociodemographic and cognitive characteristics of individuals with confirmed or suspected ARBD presenting to alcohol services warrants further investigation.

Methods

This study retrospectively examined rates of cognitive impairment using Montreal Cognitive Assessment (MoCA) data from 300 adults who visited three alcohol support services. We demonstrate that 55.3% of the sample had significant levels of cognitive impairment. Females' cognitive performance was disproportionately negatively affected by historical alcohol use relative to males.

Results

The analysis identified four categories of participants, and the majority had a long history (+10 years) of alcohol use and were still actively drinking. Those taking part in active treatment for ARBD or practising abstinence demonstrated lower levels of cognitive impairment. Additionally, prior access to specialised ARBD care was associated with higher MoCA scores.

Discussion

This research has identified a range of key service engagement, sociodemographic and cognitive characteristics that could be used to optimise support for those with alcohol dependence, whilst also highlighting some critical questions to be addressed in future research.

Rehabilitation Strategies for Wernicke-Korsakoff Syndrome: Physiotherapy Interventions and Management Approaches

Korsakoff syndrome and Wernicke's encephalopathy (WE) show neurological and cognitive deficits. Wernicke-Korsakoff syndrome (WKS) is a compound neurological condition. The cause of this neurological condition could be the consumption of alcohol regularly for a chronic duration. A tailored rehabilitation protocol that focuses on cognitive and physical deficiencies was implemented along with thiamine supplementation for managing a case of a 49-year-old male patient who had a history of high alcohol consumption and was exhibiting typical signs of WKS. After planning a proper physiotherapy plan, it is necessary to look after the patient's progress along with re-evaluation, which reveals notable gains in cognitive function, memory, and functional independence. There is a dearth of research on the impact of physical therapy in managing WKS. The above case report reflects the benefits of combining physiotherapy, cognitive rehabilitation, and balance training to improve patient functionality and independence. Tailored rehabilitation interventions like the Benson relaxation method (BRM), brain gym exercises, Frenkel's exercise, electrical stimulation, sensorimotor training, basic body awareness therapy (BBAT), and gait training can be used to enhance a patient's quality of life. Addressing individual needs is essential in managing WKS, focusing on the importance of comprehensive care beyond cognitive rehabilitation alone.

Altered learning and transfer abilities in Korsakoff's syndrome depending on task complexity

Korsakoff's syndrome (KS) is characterized by episodic memory impairment due to damage to the medial diencephalic structures. Although commonly associated with chronic alcoholism, starvation due to the hunger strike is one of its nonalcoholic causes. Learning the stimulus-response associations and transferring the just-learned associations to novel combinations were previously tested by specific tasks in memory-impaired patients with hippocampal, basal forebrain, and basal ganglia damage. To add to this previous research, we aimed to use the same tasks in a group of patients with hunger strike-related KS presenting a stable isolated amnestic profile. Twelve patients with hunger strike-related KS and matched healthy controls were tested in two tasks varying in task complexity. Each task included two phases: the initial phase is feedback-based learning of (simple vs. complex) stimulus-response associations, and the following phase is transfer generalization (in the presence vs. absence of feedback). On a task involving simple associations, five patients with KS failed to learn the associations, while the other seven patients showed intact learning and transfer. On the other task involving more complex associations, seven patients showed slower learning and failed at transfer generalization, whereas the other five patients failed even at the acquisition phase. These findings of a task-complexity-related impairment on associative learning and transfer represent a distinct pattern from the spared learning but impaired transfer previously observed on these tasks in patients with medial temporal lobe amnesia.

Eye Movements as Proxy for Visual Working Memory Usage: Increased Reliance on the External World in Korsakoff Syndrome

In the assessment of visual working memory, estimating the maximum capacity is currently the gold standard. However, traditional tasks disregard that information generally remains available in the external world. Only when to-be-used information is not readily accessible, memory is taxed. Otherwise, people sample information from the environment as a form of cognitive offloading. To investigate how memory deficits impact the trade-off between sampling externally or storing internally, we compared gaze behaviour of individuals with Korsakoff amnesia (n = 24, age range 47-74 years) and healthy controls (n = 27, age range 40-81 years) on a copy task that provoked different strategies by having information freely accessible (facilitating sampling) or introducing a gaze-contingent waiting time (provoking storing). Indeed, patients sampled more often and longer, compared to controls. When sampling became time-consuming, controls reduced sampling and memorised more. Patients also showed reduced and longer sampling in this condition, suggesting an attempt at memorisation. Importantly, however, patients sampled disproportionately more often than controls, whilst accuracy dropped. This finding suggests that amnesia patients sample frequently and do not fully compensate for increased sampling costs by memorising more at once. In other words, Korsakoff amnesia resulted in a heavy reliance on the world as 'external memory'.

Prevalences and Indications of Psychotropic Drug Prescriptions in Nursing Home Residents with Korsakoff Syndrome

Psychotropic drugs (PD) are often prescribed to nursing home residents with Korsakoff syndrome (KS). It is unknown whether these drugs are prescribed correctly or whether they are prescribed off-label, for example, to treat behavioral symptoms. To get more insight into PD prescriptions, a descriptive study was performed. The type, category and indications of PD prescriptions of 285 participants were analyzed using medication charts and questionnaires. Behavioral symptoms were investigated with the Neuropsychiatric Inventory-Questionnaire. The results showed that atypical antipsychotics (57.1%) were prescribed more frequently than typical antipsychotics (49.3%). Of the antidepressants, selective serotonin/norepinephrine reuptake inhibitors (63.1%) were most frequently prescribed, followed by tricyclic antidepressants (23.4%). Of the benzodiazepines, anxiolytics (85.7%) were more prescribed than hypnotics (24.5%). Besides psychiatric disorders, PD were also prescribed to treat behavioral symptoms varying from 29.9% (antipsycho-tics) to 26.3% (benzodiazepines) and 9.3% (antidepressants). Furthermore, prescriptions were high if behavioral symptoms were present. To conclude, PD are often prescribed to residents with KS for an unapproved indication, namely behavioral symptoms. Additional research is needed to obtain further insight into the current prescribing culture and the effectiveness of PD. The insights thus obtained may, ultimately, contribute to the appropriate prescription of PD for people with KS.

Neuropsychiatric Alterations in a Patient Diagnosed with Advanced Korsakoff's Syndrome: Clinical Case of Low Incidence and Prevalence in Colombia

Korsakoff's syndrome (KS) is an insidious and progressive neuropsychiatric disorder that affects specific neurocognitive functioning, especially in tasks that require sustained attention, memory, executive functions, and visuospatial functioning. Usually, this disease generates neuropsychiatric complications that worsen the quality of life (QOL) of patients in the medium term. We present a case of a 63-year-old male who presented with a diagnosis of advanced Korsakoff's syndrome and has a clinical history of recurrent memory loss and a history of alcohol abuse. The patient showed difficulty manipulating immediate information, associated with a possible frontal lobe dysfunction, and inability to remember material given through the auditory pathway. The patient showed a psychiatric clinical picture which is constantly worsening his and his immediate caregiver's QOL. The data obtained demonstrate that the patient presents a progressive cognitive impairment, which in the short term is correlated with Korsakoff-type dementia. It is suggested to carry out functional neurorehabilitation plans aimed at improving the QOL of the patient, his immediate caregiver, and future people with this type of diagnosis.

The Use of an Errorless Learning Application to Support Re-Learning of (Instrumental) Activities for People Living with Korsakoff Syndrome

Korsakoff syndrome (KS) is a severe neuropsychiatric syndrome derived from acute thiamine deficiency and concomitant alcohol use disorders. KS patients need lifelong assistance because of the severity of their cognitive problems. In clinical practice and research, errorless learning has proven to be an effective cognitive rehabilitation method for patients with KS. Our study focused on optimizing errorless learning by introducing new software technology to support the training process of errorless learning. Although the benefits of errorless learning for patients with Korsakoff's syndrome have been thoroughly investigated, it is currently unclear whether new technology could contribute to better learning and maintenance of everyday tasks. Therefore, an errorless learning application was built. This device is a web application and can be used on a tablet, laptop, or smartphone. The application allows clinicians and researchers to insert pictures, videoclips, timers, and audio fragments in the different steps of an errorless learning training plan. This way, the different steps are visible and easy to follow for patients. Moreover, it ensures as a learning method that the training is executed exactly the same way for each and every training. The aim of this study was twofold: to examine whether the use of the errorless learning application is effective, and whether it leads to better results than a regular errorless learning of everyday activities. In total, 13 patients with KS were trained in instrumental activities of daily living by means of the application, and 10 patients were trained with traditional instructions. Results showed an equal improvement for both training methods. Importantly, the technology group could better remember the training when probed at a later moment than the traditional errorless learning group. These results are promising for further development of novel technology to support errorless learning applications in clinical practice.

Korsakoff syndrome: An overlook (Review)

This review aimed to analyze the latest neurobiological findings regarding Korsakoff syndrome, since alcoholism is the most prevalent addiction worldwide. In addition, we analyzed the optimal treatment that can be administered in order to minimize the symptoms and improve the outcome of these patients. The disruption of memory circuits within the brain of alcoholic patients results in the amnestic syndrome known as Korsakoff syndrome. It is generally characterized by a chronic neuropsychiatric syndrome caused by vitamin B1 (thiamine) deficiency. Other categories of patients can develop Korsakoff syndrome without consuming alcohol such as AIDS patients, terminally ill cancer patients, or patients with chronic infections and malnutrition. Vitamin B1 is required in the Krebs cycle for production of adenosine triphosphate (ATP). It is also a cofactor in the production of acetylcholine and certain neurotransmitters. Alcohol consumption can decrease the intake, gastrointestinal absorption and cellular utilization of vitamin B1. Treatment of alcohol withdrawal along with high doses of vitamin B1 can improve the general outcome of patients. A small percentage of patients can recover from Wernicke's encephalopathy with no permanent brain damage. The onset of Korsakoff syndrome darkens the prognosis. Alcohol abstinence is an absolute recommendation and prevents the extension of neural damage.

Do Errorless Methods Improve Discharge Medication Instruction and Adherence?

PURPOSE AND DESIGN

Postdischarge adverse drug events are a national issue, and effective inpatient instruction may help. Therefore, this intervention study examined whether using errorless teaching/learning methods including pictorial medication cards (ETL + card) improved RN teaching and patient medication adherence among persons with cognitive challenges (PWCCs).

METHODS

Convenience samples of RNs and PWCCs from a 24-bed rehabilitation unit provided baseline data. RNs implemented ETL + card, and postintervention data were collected. Adapted and investigator-designed instruments had preliminary reliability/validity.

FINDINGS

Postintervention RNs demonstrated more teaching strategies (p = .003), and teaching satisfaction rose from 0% to 50%. Minutes per teaching interaction were unchanged (p > .05). Baseline patients filled a higher number (p = .02) but a lower percentage (67%) of their prescriptions than did postintervention patients (85%). Medication dose adherence scores were unchanged (p > .05).

CONCLUSIONS

ETL + card improved RN teaching and possibly patient adherence. Further study is warranted.

CLINICAL RELEVANCE

ETL + card may help PWCCs achieve safe medication self-management.

The contribution of mamillary body damage to Wernicke's encephalopathy and Korsakoff's syndrome

Histopathological alterations of the mamillary bodies are the most conspicuous and the most consistent neuropathological features of several disorders that occur after severe thiamine deficiency, such as Wernicke's encephalopathy and Korsakoff's syndrome. Moreover, they are among the few abnormalities that are visible to the naked eye in these disorders. With a lifetime prevalence of approximately 1.3%, Wernicke's encephalopathy is by far the most frequent cause of damage to the mamillary bodies in humans. Still, there is a persisting uncertainty with regard to the development and the clinical consequences of this damage, because it is virtually impossible to study in isolation. As a rule, it always occurs alongside neuropathology in other subcortical gray matter structures, notably the medial thalamus. Converging evidence from other pathologies and animal experiments is needed to assess the clinical impact of mamillary body damage and to determine which functions can be attributed to these structures in healthy subjects. In this chapter, we describe the history and the current state of knowledge with regard to thiamine deficiency disorders and the contribution of mamillary body damage to their clinical presentations.

A systematic review of treatments for alcohol-related cognitive impairment: lessons from the past and gaps for future interventions

Alcohol-related cognitive impairment (ARCI) is highly prevalent among patients with alcohol dependence. Although it negatively influences treatment outcome, this condition is underdiagnosed and undertreated. The aim of this systematic review is to investigate the existing evidence regarding both cognitive and pharmacological interventions for ARCI. We systematically reviewed PubMed, Scopus and Science direct databases up to May 2019 and followed the PRISMA guidelines. The quality of the studies was assessed using the Jadad Scale. Twenty-six studies were eligible for inclusion (14 referring to neuropsychological interventions and 12 to pharmacological treatments). Among neuropsychological interventions, computerised treatments, errorless learning and component method showed positive effects on working memory, memory measures and general cognitive function. On the other hand, thiamine, memantine and methylphenidate improved working memory, long-term memory and general cognitive function. Nevertheless, these studies have several limitations, such as small sample size, lack of replication of the results or low specificity of the interventions. Therefore, no gold-standard intervention can yet be recommended for clinical practice, and further research based on promising strategies (e.g. digital interventions, thiamine) is required.

Caregivers' perspectives on good care for nursing home residents with Korsakoff syndrome

BACKGROUND

In the Netherlands, people with severe cognitive deficits due to Korsakoff syndrome are generally admitted to a specialized nursing home. Professional caregivers experience that these residents are often not aware of their deficits, and consequently, their willingness to accept care is relatively low. However, these residents need permanent support when performing daily tasks due to severe cognitive deficits. The combination of objective care needs and low subjective responsiveness makes caring for people with Korsakoff syndrome a complex undertaking. It is unknown how professional caregivers deal with this complex task and how they manage the associated ethical challenges.

OBJECTIVES

The aim of this study was to explore the professional caregivers' perspectives on good care for residents with Korsakoff syndrome.

METHODS

A qualitative study design was used. Data were collected via semi-structured interviews. The Framework Method was used for the thematic analyses of the interview data.

PARTICIPANTS AND RESEARCH CONTEXT

Five specialized nursing homes participated in this study. Twelve professional caregivers, including nurses, nursing assistants, and support workers, were selected based on the ability to provide rich information on the study topics and to capture a variety of demographic and professional characteristics.

ETHICAL CONSIDERATIONS

The institutional review board of the VU University Medical Center Amsterdam approved the research protocol. The study was conducted in accordance with the ethical principles for medical research involving human subjects.

FINDINGS

Three perspectives on good care emerged: (1) making daily life a joint effort, (2) being steadfast, and (3) treating with respect.

DISCUSSION AND CONCLUSION

Professional caregivers try to achieve responsiveness in people with Korsakoff syndrome in three different ways. These perspectives reflect fundamentally different views on the care relationship and the autonomy of the resident. By elucidating the three perspectives, we hope to promote the practitioners' reflection on their own ideas about good care for people with Korsakoff syndrome.

Chunking to improve verbal forward spans in Korsakoff's syndrome

Chunking is a mnemonic strategy that involves organizing information into appropriate units. Our article examined the use of this strategy on forward and backward span performance in Korsakoff's syndrome. Fifteen patients with Korsakoff's syndrome and 17 age-and-education matched healthy controls participated to the study. Digit span performance (both forward and backward) was tested before and after chunking training. Results demonstrated an increased performance on the forward spans after chunking training in the patients with Korsakoff's syndrome, but no beneficial effect was observed on the backward spans in these participants. Controls demonstrated a chunking effect on both forward and backward span performance. Our findings suggest that a simple training in chunking may be useful as part of a cognitive strategy training for improving working memory performance in patients with Korsakoff's syndrome.

The effect of errorless learning on psychotic and affective symptoms, as well as aggression and apathy in patients with Korsakoff's syndrome in long-term care facilities

ABSTRACTObjectives:Errorless learning is a promising rehabilitation principle for learning tasks in patients with amnesia, including patients with Korsakoff's syndrome. Errorless learning might possibly also contribute to decreases in behavioral and psychiatric problems, as patients in long-term care facilities become more independent after training. The aim of this study was to examine the effects of errorless learning on potential changes in psychotic and affective symptoms, aggression and apathy, in contrast with a control group who received care as usual.

METHODS

The current study is a quasi-experimental study on errorless learning and psychotic and affective symptoms, aggression, and apathy in patients with Korsakoff's syndrome, living in long-term care facilities for patients with Korsakoff's syndrome (KS) in the Netherlands. The GIP-28, HoNOS-ABI, and NVCL-20 were administered to a group of patients with KS who received errorless learning training (n = 51) and a patient control group who received care as usual (n = 31). Wilcoxon Signed-Rank Tests were performed to examine psychotic and affective symptoms, aggression, and apathy at baseline and at follow-up in the errorless learning group and the control group.

RESULTS

Errorless learning training effectively reduced psychotic symptoms (including provoked confabulations), affective symptoms, and agitation/aggression. There were no significant changes (increases nor decreases) in the control group. Levels of apathy were stable over time in both groups.

CONCLUSIONS

Results with respect to psychotic and affective symptoms, aggression, and apathy are discussed in depth. Patients with KS can become more autonomous in a cared for setting using errorless learning principles. This might also result in decreases in behavioral and psychiatric problems in patients.

Visuospatial declarative learning despite profound verbal declarative amnesia in Korsakoff's syndrome

Korsakoff's syndrome (KS) is a neuropsychiatric disorder characterised by severe amnesia. Although the presence of impairments in memory has long been acknowledged, there is a lack of knowledge about the precise characteristics of declarative memory capacities in order to implement memory rehabilitation. In this study, we investigated the extent to which patients diagnosed with KS have preserved declarative memory capacities in working memory, long-term memory encoding or long-term memory recall operations, and whether these capacities are most preserved for verbal or visuospatial content. The results of this study demonstrate that patients with KS have compromised declarative memory functioning on all memory indices. Performance was lowest for the encoding operation compared to the working memory and delayed recall operation. With respect to the content, visuospatial memory was relatively better preserved than verbal memory. All memory operations functioned suboptimally, although the most pronounced disturbance was found in verbal memory encoding. Based on the preserved declarative memory capacities in patients, visuospatial memory can form a more promising target for compensatory memory rehabilitation than verbal memory. It is therefore relevant to increase the number of spatial cues in memory rehabilitation for KS patients.

Korsakoff's syndrome: a critical review

In this review, we present a survey on Korsakoff's syndrome (KS), a residual syndrome in patients who suffered from a Wernicke encephalopathy (WE) that is predominantly characterized by global amnesia, and in more severe cases also by cognitive and behavioral dysfunction. We describe the history of KS and its definition, its epidemiology, and the lack of consensus criteria for its diagnosis. The cognitive and behavioral symptoms of KS, which include anterograde and retrograde amnesia, executive dysfunction, confabulation, apathy, as well as affective and social-cognitive impairments, are discussed. Moreover, recent insights into the underlying neurocognitive mechanisms of these symptoms are presented. In addition, the evidence so far on the etiology of KS is examined, highlighting the role of thiamine and alcohol and discussing the continuity hypothesis. Furthermore, the neuropathology of KS is reviewed, focusing on abnormalities in the diencephalon, including the mammillary bodies and thalamic nuclei. Pharmacological treatment options and nonpharmacological interventions, such as those based on cognitive rehabilitation, are discussed. Our review shows that thiamine deficiency (TD) is a crucial factor in the etiology of KS. Although alcohol abuse is by far the most important context in which TD occurs, there is no convincing evidence for an essential contribution of ethanol neurotoxicity (EN) to the development of WE or to the progression of WE to KS. Future research on the postmortem histopathological analysis of brain tissues of KS patients is crucial for the advancement of our knowledge of KS, especially for associating its symptoms with lesions in various thalamic nuclei. A necessary requirement for the advancement of studies on KS is the broad acceptance of a comprehensive definition and definite diagnostic criteria. Therefore, in this review, we propose such a definition of KS and draft outlines for prospective diagnostic criteria.

The effect of errorless learning on quality of life in patients with Korsakoff's syndrome

BACKGROUND

Errorless learning (EL) is a promising rehabilitation principle for (re)learning instrumental activities in patients with amnesia, including patients with Korsakoff's syndrome (KS). Successfully (re)learning tasks might improve the sense of competence and independence, and subsequently the quality of life. Quality of life in patients with KS has received limited attention, and no studies have been conducted to experimentally examine the effect of EL on quality of life in patients in this patient group.

MATERIALS AND METHODS

The QUALIDEM, an observation scale for quality of life, was completed by professional nurses before and after EL training in a group of fifty-one patients with KS. This scale was also completed for a group of thirty-one control patients receiving care as usual but no EL training.

RESULTS

Quality of life was significantly increased on eight of the nine subscales in the Korsakoff group who participated in an EL training. There was a trend toward a significant increase in "positive affect" (ie, the ninth subscale). In contrast, no changes over time were found on any of the subscales in the control group that did not participate in any EL training.

CONCLUSION

Despite severe memory impairments, patients with KS still have the potential to (partially) (re)learn tasks using EL. This potential should be exploited, as the successes of (re)-learning might improve the quality of life of Korsakoff patients in nursing homes.

Procedural Learning and Memory Rehabilitation in Korsakoff's Syndrome - a Review of the Literature

Korsakoff's syndrome (KS) is a chronic neuropsychiatric disorder caused by alcohol abuse and thiamine deficiency. Patients with KS show restricted autonomy due to their severe declarative amnesia and executive disorders. Recently, it has been suggested that procedural learning and memory are relatively preserved in KS and can effectively support autonomy in KS. In the present review we describe the available evidence on procedural learning and memory in KS and highlight advances in memory rehabilitation that have been demonstrated to support procedural memory. The specific purpose of this review was to increase insights in the available tools for successful memory rehabilitation and give suggestions how to apply these tools in clinical practice to increase procedural learning in KS. Current evidence suggests that when memory rehabilitation is adjusted to the specific needs of KS patients, this will increase their ability to learn procedures and their typically compromised autonomy gets enhanced.

A Case of Chronic Wernicke's Encephalopathy: A Neuropsychological Study

A 54-year-old woman was referred to our Korsakoff Center because of extensive cognitive problems following acute Wernicke's encephalopathy (WE). She had a relatively short history of alcohol abuse and was found lying on the floor in her home by her son. After 5 days without treatment, she was diagnosed with WE in a general hospital. During the course of the disease, minimal change to the acute situation occurred, with chronic confusion, attention deficits, and incoherent behavior symptoms most notable unlike classical Korsakoff's syndrome. Neuropsychological assessment after 4 and 16 months after admission to the hospital revealed global cognitive decline, with striking impairments in attentional, executive, and memory functions. The present case study suggests that the state of confusion and the neuropsychological symptoms in WE can become chronic in case of very late treatment. We therefore recommend that confused alcoholics should receive appropriate parenteral thiamine according to the current clinical standards.