The Korsakoff syndrome: clinical aspects, psychology and treatment

Wernicke Encephalopathy: Typical and Atypical Findings in Alcoholics and Non-Alcoholics and Correlation with Clinical Symptoms

PURPOSE

Clinical diagnosis of Wernicke encephalopathy (WE) can be challenging due to incomplete presentation of the classical triad. The aim was to provide an update on the relevance of standard MRI and to put typical and atypical imaging findings into context with clinical features.

METHODS

In this two-center retrospective observational study, the local radiology information system was searched for consecutive patients with clinical or imaging suspicion of WE. Two independent raters evaluated T2-weighted imaging (WI), fluid-attenuation inversion recovery (FLAIR), diffusion WI (DWI), T2*WI and/or susceptibility WI (SWI), and contrast-enhanced (CE)-T1WI, and noted the involvement of typical (i.e., mammillary bodies (MB), periaqueductal grey (PAG), thalamus, hypothalamus, tectal plate) and atypical (all others) lesion sites. Unusual signal patterns like hemorrhages were also documented. Reported clinical features together with the diagnostic criteria of the latest guidelines of the European Federation of Neurological Societies (EFNS) were used to test for relationships with MRI biomarkers.

RESULTS

47 patients with clinically confirmed WE were included (Jan '99-Apr '23; mean age, 53 yrs; 70% males). Interrater reliability for imaging findings was substantial (κ = 0.71), with lowest agreements for T2WI (κ = 0.85) compared to all other sequences and for PAG (κ = 0.65) compared to all other typical regions. In consensus, 77% (n = 36/47) of WE cases were rated MRI positive, with FLAIR (n = 36/47, 77%) showing the strongest relation (χ2 = 47.0; P < 0.001) compared to all other sequences. Microbleeds in the MB were detected in four out of ten patients who received SWI, not visible on corresponding T2*WI. Atypical findings were observed in 23% (n = 11/47) of cases, always alongside typical findings, in both alcoholics (n = 9/44, 21%) and non-alcoholics (n = 2/3, 67%). Isolated involvement of structures, explicitly PAG (n = 4/36; 11%) or MB (n = 1/36; 3%), was present but observed less frequently than combined lesions (n = 31/36; 86%). A cut-off width of 2.5 mm for the PAG on 2D axial FLAIR was established between cases and age- and sex-matched controls. An independent association was demonstrated only between short-term memory loss and changes in the MB (OR = 2.2 [95% CI: 1.1-4.5]; P = 0.024). In retrospect, EFNS criteria were positive (≥ 2 out of 4) in every case, but its count (range, 2-4) showed no significant (P = 0.427) relationship with signal changes on standard MRI.

CONCLUSION

The proposed sequence protocol (FLAIR, DWI, SWI and T1WI + CE) yielded good detection rates for neuroradiological findings in WE, with SWI showing microbleeds in the MB with superior detectability. However, false negative results in about a quarter of cases underline the importance of neurological alertness for the diagnosis. Awareness of atypical MRI findings should be raised, not only in non-alcoholics. There is limited correlation between clinical signs and standard MRI biomarkers.

Clinical Heterogeneity in Alzheimer's Disease: A Possible New Amnesic Phenotype

We rediscovered a phenotype of AD known in the early 1900s as presbyophrenia, but then forgotten, and renamed as confabulation-misidentification phenotype. The phenotype includes diencephalic amnesia whose prototype is Korsakoff syndrome. The main features are anterograde and retrograde amnesia with marked disorientation and confabulation, executive impairments, reduced insight and attention deficits, misidentification, minor hallucination and other delusions, behavioral disturbances, and early anxiety. In this article, we summarize what we have discovered about the new phenotype and what is still missing to confirm this diencephalic variant of AD.

Neurologic complications of thiamine (B1) deficiency following bariatric surgery in adolescents

BACKGROUND

The prevalence of obesity among children and adolescents is rising and poses a major health concern. Bariatric surgery is well established in adults and has become an option for adolescents. Thiamine (B1) deficiency is common following bariatric surgery in adults. It may present as Beri-Beri, Wernicke encephalopathy, or Korsakoff psychosis.

OBJECTIVE

Our aim was to describe the clinical features, diagnosis, and treatment of adolescents who presented with B1 deficiency after bariatric surgery at one center, and to summarize the data from the literature.

PATIENTS

Three adolescents with morbid obesity (two boys and one girl, aged 15.5 to- 17-years-old), presented at Schneider Children's Medical Center of Israel with progressive lower limb pain and weakness 2-3 month following a bariatric procedure (sleeve gastrectomy or narrowing of a bariatric band). The girl also had upper limb involvement and cerebellar signs. All three were non-compliant with micronutrient supplementation. After admission, they received intravenous B1 and oral multivitamin supplementation, and their symptoms improved considerably.

CONCLUSIONS

Micronutrient supplementation following bariatric surgery is crucial to prevent deficiencies. In adolescents, compliance with micronutrient supplementation should be assessed before and after such surgery. Thiamine deficiency may cause polyneuropathy, among other symptoms. Treatment reduces the severity of neurological complications.

Personality traits and personality problems in Korsakoff syndrome patients

Personality research is of relevance because it provides insights into the psychological strengths and vulnerabilities of a person. Korsakoff's syndrome (KS) is a severe neuropsychiatric disorder following acute thiamine deficiency, usually as a consequence of alcohol-use disorders. Research on personality traits of KS patients is currently limited. The aim of the current exploratory study was therefore to examine the personality traits and problems of KS patients. We assessed self-reported and informant-reported personality traits and problems in institutionalized KS patients (n = 30). Results indicate that the psychotic personality organization was more frequently present in KS patients compared to a psychiatric reference population, leading to increased vulnerability for the development of severe psychiatric issues. Informants observed more premorbid and current cluster B ("emotional") and C ("anxious") personality behavior in comparison to the general population. Also, rigid- and socially avoidant behavior in KS patients was observed to increase over the years. They also observed personality problems such as emotional-, unpredictable-, dramatic-, anxious and fearful behavior in the present and in the past. KS patients reported themselves as healthy individuals, indicating a lack of self-awareness. We recommend training programs for the medical team focussed on psycho-education and supportive interventions for patients with complex personality problems concomitant to KS.

The mediodorsal thalamus in executive control

Executive control, the ability to organize thoughts and action plans in real time, is a defining feature of higher cognition. Classical theories have emphasized cortical contributions to this process, but recent studies have reinvigorated interest in the role of the thalamus. Although it is well established that local thalamic damage diminishes cognitive capacity, such observations have been difficult to inform functional models. Recent progress in experimental techniques is beginning to enrich our understanding of the anatomical, physiological, and computational substrates underlying thalamic engagement in executive control. In this review, we discuss this progress and particularly focus on the mediodorsal thalamus, which regulates the activity within and across frontal cortical areas. We end with a synthesis that highlights frontal thalamocortical interactions in cognitive computations and discusses its functional implications in normal and pathological conditions.

Wernicke's Encephalopathy in Acute and Chronic Kidney Disease: A Systematic Review

Thiamine (vitamin B1) deficiency is relatively common in patients with kidney disease. Wernicke's encephalopathy (WE) is caused by vitamin B1 deficiency. Our aim was to systematically review the signs and symptoms of WE in patients with kidney disease. We conducted a systematic literature review on WE in kidney disease and recorded clinical and radiographic characteristics, treatment and outcome. In total 323 manuscripts were reviewed, which yielded 46 cases diagnosed with acute and chronic kidney disease and WE published in 37 reports. Prodromal characteristics of WE were loss of appetite, vomiting, weight loss, abdominal pain, and diarrhea. Parenteral thiamine 500 mg 3 times per day often led to full recovery, while Korsakoff's syndrome was found in those receiving low doses. To prevent WE in kidney failure, we suggest administering high doses of parenteral thiamine in patients with kidney disease who present with severe malnutrition and (prodromal) signs of thiamine deficiency.

Molecular mechanisms of alcohol's effects on the human body: A review and update

Alcohol consumption has been linked to numerous negative health outcomes although it has some beneficial effects on moderate dosages, the most severe of which being alcohol-induced hepatitis. The number of people dying from this liver illness has been shown to climb steadily over time, and its prevalence has been increasing. Researchers have found that alcohol consumption primarily affects the brain, leading to a wide range of neurological and psychological diseases. High-alcohol-consumption addicts not only experienced seizures, but also ataxia, aggression, social anxiety, and variceal hemorrhage that ultimately resulted in death, ascites, and schizophrenia. Drugs treating this liver condition are limited and can cause serious side effects like depression. Serine-threonine kinases, cAMP protein kinases, protein kinase C, ERK, RACK 1, Homer 2, and more have all been observed to have their signaling pathways disrupted by alcohol, and alcohol has also been linked to epigenetic changes. In addition, alcohol consumption induces dysbiosis by changing the composition of the microbiome found in the gastrointestinal tract. Although more studies are needed, those that have been done suggest that probiotics aid in keeping the various microbiota concentrations stable. It has been argued that reducing one's alcohol intake may seem less harmful because excessive drinking is a lifestyle disorder.

Alcohol-related dementia

Dementia is one of the leading causes of death both in the UK and worldwide. Approximately 1 million people have been diagnosed with this condition in the UK. Although there are many types of dementia, this article will focus on alcohol-related dementia. Alcohol has become a leading cause of death in the 50-69-year age group in England, and with consumption rising rapidly, there is an increased risk that young and middle-aged people will develop alcohol-related dementia in the future. The aim of this article is to review the evidence base and discuss whether alcohol-related dementia is a sub-class of dementia or a separate entity.

Over a Century of Study and Still Misunderstood: Recognizing the Spectrum of Acute and Chronic Wernicke-Korsakoff Syndrome

The aim of this study was to objectively evaluate the hypothesis that the neuropsychological presentation of Korsakoff's syndrome, the chronic phase of Wernicke-Korsakoff syndrome (WKS), is invariably a severe, selective amnesia against a background of relatively preserved general intellectual functions in a consecutive clinical sample. An analysis of the neuropsychological profiles of nine cases with a recorded history of WKS was undertaken. All cases were adult males (ages 32 to 70) with a long history of alcohol use disorder. Eight cases were chosen retrospectively on a consecutive basis from patient referrals. One additional case was recruited prospectively. Conventional understanding and some current opinion of Korsakoff's syndrome predicts anterograde memory to be consistently more impaired than other cognitive abilities, but this was not found in this case series. The Mean Wechsler Delayed Memory Index was not significantly different from the Wechsler Full-Scale IQ (FSIQ), p = 0.130. Regression of Delayed Memory on FSIQ produced a non-significant intercept, p = 0.213. The 'hallmark' criterion of anterograde memory score at least 20 points less than intelligence score was observed in four of eight cases with available data, equating to a 'sensitivity' of 50%. Three of eight cases with available data had an FSIQ less than the memory score. Contrary to a common view, general intellectual function was not consistently preserved in Korsakoff's syndrome relative to memory function. This study illustrates one of the specific merits of case series, namely, to critique an established view. Clinicians and researchers should expand their diagnostic criteria for Korsakoff's syndrome to include more variable cognitive phenotypes, including a potentially reversible dementia-like impairment of variable severity, and focus on potential treatment opportunities.

Impaired Executive Functioning Associated with Alcohol-Related Neurocognitive Disorder including Korsakoff's Syndrome

(1) Background: chronic alcohol use is consistently associated with impaired executive functioning, but its profile across the spectrum from mild to major alcohol-related cognitive impairment is, to date, unclear. This study aims to compare executive performances of patients with alcohol-induced neurocognitive disorder, including Korsakoff's syndrome (KS), by using a computerized assessment battery allowing a fine-grained and precise neuropsychological assessment; (2) Methods: performances of 22 patients with alcohol-related cognitive impairment (ARCI) and 20 patients with KS were compared to those of 22 matched non-alcoholic controls. All participants were diagnosed in accordance with DSM-5-TR criteria and were at least six weeks abstinent from alcohol prior to assessment. Executive function was evaluated using four subtests of Cambridge Neuropsychological Test Automated Battery (CANTAB®); (3) Results: significant differences between groups were found on spatial working memory (updating), sustained attention and inhibitory control, set shifting, and planning. Healthy controls performed significantly better than both patient groups (Games-Howell post hoc; p < 0.05), but no differences in performance were found between the ARCI and KS group; (4) Conclusions: ARCI and KS patients showed significant executive impairments, most prominent in updating, set-shifting and general planning abilities. Findings suggest equivalent levels of executive function in ARCI and KS patients. Our results highlight executive function as a significant hallmark of alcohol-induced neurocognitive disorder and stipulate the importance of early assessment and evaluation of skills to guide treatment.

Successful word retraining, maintenance and transference of practice to everyday activities: A single case experimental design in early onset alcohol-induced brain damage

Word retraining programs have been shown to improve naming ability post-stroke and in progressive aphasias. Here, we investigated benefits for a 22-year-old Danish man (DJ), whose difficulties followed brain damage from heavy alcohol misuse. Using a multiple baseline-across-behaviours design (target behaviour: retrieval of word list items), DJ completed a 4-week "Look, Listen, Repeat" program on a computer. Ninety personally relevant target words were selected to create three matched lists. List 1 was trained for 10 sessions over 2 weeks, followed by 9 sessions for List 2 over 2 weeks, while the third list remained untrained. Naming performance was evaluated at baseline, during the intervention, and at 1 and 4 months post-training. Naming improved following each intervention block (p < .001), with only one data point overlapping between the baseline and treatment phases for trained items. Untrained words remained unchanged (p = 1.00), with 50% of data points non-overlapping across baseline to treatment phases. Performance was maintained over time, and appeared to generalize, with DJ naming more trained objects in their natural setting (85%) than untrained items (64%). While more evidence is needed, brief (20-minute), intensive (5-day/week) word retraining programs may assist word retrieval for people with brain damage associated with alcohol misuse.

Observations on the Clinical Features of the Wernicke-Korsakoff Syndrome

This paper begins with a short case report of florid, spontaneous confabulation in a 61-year-old man with an alcohol-induced Wernicke-Korsakoff syndrome. His confabulation extended across episodic and personal semantic memory, as well as orientation in time and place, as measured on Dalla Barba's Confabulation Battery. Five other brief case summaries will then be presented, followed by a summary of the clinical, neurological, and background neuropsychological findings in three earlier series of Korsakoff patients. These observations will be considered in light of Wijnia's recent and my own, earlier reviews of the Korsakoff syndrome. Taken together, they indicate the need for a multi-faceted approach (clinical, neurological, neuropsychological, and neuroimaging) to the assessment and diagnosis of the disorder.

When Do Korsakoff Patients Justify Immoral Behaviors? The Influence of Premorbid Delinquency and Self-Other Perspectives in Moral Decision-Making and Moral Reasoning

Korsakoff's syndrome (KS) is a chronic neuropsychiatric disorder caused by a vitamin B1 deficiency. KS is characterized by profound amnesia and often accompanied by poor executive functioning, decreased social-cognitive abilities, and difficulties in behavioral regulation. As moral behaviors and attitudes may provide insight in socio-behavioral interactions, the current study aimed to evaluate everyday moral maturity by administering self- versus other-oriented moral dilemmas in a group of KS patients (n = 20) and healthy controls (n = 20). Responses were scored according to the Kohlberg stages of moral reasoning. Furthermore, we assessed premorbid delinquency and current neurocognitive functioning as possible relevant factors. Our results show that KS patients were prone to lower levels of moral maturity when confronted with moral dilemmas relating to themselves, compared to dilemmas relating to (un)personal others in KS patients, while healthy subjects showed an opposite pattern. Moral immaturity could find its origin already before the onset of the KS diagnosis, as suggested by the elevated premorbid levels of delinquent behavior and correlation between premorbid delinquency and moral maturity in KS. Lower moral maturity could therefore be a possible predisposing factor to both delinquency and later development of Korsakoff's syndrome.

Psychosis Caused by a Somatic Condition: How to Make the Diagnosis? A Systematic Literature Review

BACKGROUND

First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes.

METHODS

We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies.

RESULTS

We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided.

CONCLUSION

This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.

Self-Reported Pain and Pain Observations in People with Korsakoff's Syndrome: A Pilot Study

Korsakoff's syndrome (KS) is a chronic neuropsychiatric disorder. The large majority of people with KS experience multiple comorbid health problems, including cardiovascular disease, malignancy, and diabetes mellitus. To our knowledge pain has not been investigated in this population. The aim of this study was to investigate self-reported pain as well as pain behavior observations reported by nursing staff. In total, 38 people diagnosed with KS residing in a long-term care facility for KS participated in this research. The Visual Analogue Scale (VAS), Pain Assessment in Impaired Cognition (PAIC-15), Rotterdam Elderly Pain Observation Scale (REPOS), and the McGill Pain Questionnaire-Dutch Language Version (MPQ-DLV) were used to index self-rated and observational pain in KS. People with KS reported significantly lower pain levels than their healthcare professionals reported for them. The highest pain scores were found on the PAIC-15, specifically on the emotional expression scale. Of importance, the patient pain reports did not correlate with the healthcare pain reports. Moreover, there was a high correlation between neuropsychiatric symptoms and observational pain reports. Specifically, agitation and observational pain reports strongly correlated. In conclusion, people with KS report less pain than their healthcare professionals indicate for them. Moreover, there is a close relationship between neuropsychiatric symptoms and observation-reported pain in people with KS. Our results suggest that pain is possibly underreported by people with KS and should be taken into consideration in treating neuropsychiatric symptoms of KS as a possible underlying cause.

Network Localization of Spontaneous Confabulation

OBJECTIVE

Spontaneous confabulation is a symptom in which false memories are conveyed by the patient as true. The purpose of the study was to identify the neuroanatomical substrate of this complex symptom and evaluate the relationship to related symptoms, such as delusions and amnesia.

METHODS

Twenty-five lesion locations associated with spontaneous confabulation were identified in a systematic literature search. The network of brain regions functionally connected to each lesion location was identified with a large connectome database (N=1,000) and compared with networks derived from lesions associated with nonspecific (i.e., variable) symptoms (N=135), delusions (N=32), or amnesia (N=53).

RESULTS

Lesions associated with spontaneous confabulation occurred in multiple brain locations, but they were all part of a single functionally connected brain network. Specifically, 100% of lesions were connected to the mammillary bodies (familywise error rate [FWE]-corrected p<0.05). This connectivity was specific for lesions associated with confabulation compared with lesions associated with nonspecific symptoms or delusions (FWE-corrected p<0.05). Lesions associated with confabulation were more connected to the orbitofrontal cortex than those associated with amnesia (FWE-corrected p<0.05).

CONCLUSIONS

Spontaneous confabulation maps to a common functionally connected brain network that partially overlaps, but is distinct from, networks associated with delusions or amnesia. These findings lend new insight into the neuroanatomical bases of spontaneous confabulation.

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.

Korsakoff syndrome and altered pain perception: a search of underlying neural mechanisms

OBJECTIVES

Patients with Korsakoff syndrome (KS) may have a diminished pain perception. Information on KS and pain is scarce and limited to case descriptions. The present study is the first to investigate the underlying neural mechanisms of altered pain perception in patients with KS more systematically.

METHODS

We conducted a literature search on neural correlates of pain perception in other neurocognitive disorders in which extensive research was done.

RESULTS

The brain areas that are affected in KS showed considerable overlap with the neural correlates of pain perception in other neurocognitive disorders. We discussed which different aspects of disturbed pain perception could play a role within KS, based on distinct neural damage and brain areas involved in pain perception.

CONCLUSIONS

Combining current knowledge, we hypothesize that diminished pain perception in KS may be related to lesioned neural connections between cerebral cortical networks and relays of mainly the thalamus, the periaqueductal gray, and possibly lower brain stem regions projecting to the cerebellum. Based on these neural correlates of altered pain perception, we assume that increased pain thresholds, inhibition of pain signals, and disturbed input to cerebral and cerebellar cortical areas involved in pain processing, all are candidate mechanisms in cases of diminished pain perception in KS. We recommend that clinicians need to be alert for somatic morbidity in patients with KS. Due to altered neural processing of nociceptive input the clinical symptoms of somatic morbidity may present differently (i.e. limited pain responses) and therefore are at risk of being missed.

Young Nonalcoholic Wernicke Encephalopathy Patient Achieves Remission Following Prolonged Thiamine Treatment and Cognitive Rehabilitation

Wernicke encephalopathy (WE), a neurological emergency commonly associated with alcohol use disorder, results from a severe deficiency of vitamin B1. If left untreated, patients either succumb to the illness or develop chronic Korsakoff's syndrome (KS). Recently, an increasing number of nonalcoholic WE case studies have been published, highlighting a lack of understanding of malnutrition-related disorders among high-functioning patients. We present the case of a 26 year old female who developed life-threatening WE after COVID-19-complicated obesity surgery. She experienced the full triad of WE symptoms, including eye-movement disorders, delirium, and ataxia, and suffered for over 70 days before receiving her initial WE diagnosis. Late treatment resulted in progression of WE symptoms. Despite the severity, the patient achieved remission of some of the symptoms in the post-acute phase due to prolonged parenteral thiamine injections and intensive specialized rehabilitation designed for young traumatic brain injury (TBI) patients. The rehabilitation resulted in gradual remission of amnesia symptomatology, mainly increasing her autonomy. The late recognition of this case highlights the importance of early diagnosis and prompt, targeted intervention in the management of nonalcoholic WE, as well as underscores the potential for positive outcomes after delayed treatment through intensive cognitive rehabilitation in specialized treatment centers.

Distinct Sleep Alterations in Alcohol Use Disorder Patients with and without Korsakoff's Syndrome: Relationship with Episodic Memory

Alcohol Use Disorder (AUD) results in sleep disturbances that may have deleterious impacts on cognition, especially on memory. However, little is known about the sleep architecture in patients with Korsakoff's syndrome (KS). This study aims at characterizing sleep disturbances in KS compared to AUD without KS and at specifying the relationships with cognitive impairments. Twenty-nine AUD patients (22 without KS and 7 with KS) and 15 healthy controls underwent a neuropsychological assessment and a polysomnography. The severity of sleep-disordered breathing and sleep fragmentation was similar in AUD and KS patients compared to controls. Sleep architecture differed between both patient groups: the proportion of slow-wave sleep was reduced in AUD patients only, while a lower proportion of rapid-eye movement (REM) sleep was specifically observed in KS patients. The proportion of REM sleep correlated with the severity of episodic memory deficits when AUD and KS were examined together. These data provide evidence for both similarities and specificities regarding sleep alterations in AUD patients with and without KS. They also indicate that altered sleep architecture may contribute to the pathophysiology of alcohol-related memory disorders.

Factors Associated with ADL Dependence in Nursing Home Residents with Korsakoff’s Syndrome and Other Alcohol-Related Disorders: An Explorative Cross-Sectional Study

Difficulties in performing activities of daily living (ADL) are common in patients with Korsakoff‘s syndrome (KS). The aim of this study was to identify factors associated with ADL dependence in nursing home residents with KS. This exploratory, cross-sectional study included 281 residents with KS from 9 specialized nursing homes in the Netherlands. We examined demographic, cognitive, somatic, and (neuro)psychiatric characteristics. ADL dependence was assessed with the Inter-RAI ADL Hierarchy Scale. Multivariable logistic regression analyses were used to identify factors associated with ADL dependence. Cognitive impairment (odds ratio [OR] = 7.46; 95% confidence interval [CI] = 2.10–30.5), female gender (OR = 3.23; CI, 1.21–8.78), staying in a nursing home for ≥5 years (OR = 3.12; CI, 1.24–8.33), and impaired awareness (OR = 4.25; CI, 1.56–12.32) were significantly associated with higher ADL dependence. Chronic obstructive pulmonary disease (COPD) was significantly associated with lower ADL dependence (OR = 0.31; CI, 0.01–0.84). The model explained 32% of the variance. The results suggest that when choosing interventions aimed at improving ADL functioning, special attention should be paid to residents living more than five years in the nursing home, with a female gender, with more severe cognitive impairments, and/or with COPD.

Alcohol use disorder: Neuroimaging evidence for accelerated aging of brain morphology and hypothesized contribution to age-related dementia

Excessive alcohol use curtails longevity by rendering intoxicated individuals vulnerable to heightened risk from accidents, violence, and alcohol poisoning, and makes chronically heavy drinkers vulnerable to acceleration of age-related medical and psychiatric conditions that can be life threatening (Yoon, Chen, Slater, Jung, & White, 2020). Thus, studies of factors influencing age-alcohol interactions must consider the potential that the alcohol use disorder (AUD) population may not represent the oldest ages of the unaffected population and may well have accrued comorbidities associated with both AUD and aging itself. Herein, we focus on the aging of the brains of men and women with AUD, keeping AUD contextual factors in mind. Knowledge of the potential influence of the AUD-associated co-factors on the condition of brain structure may lead to identifying modifiable risk factors to avert physical declines and may reverse or arrest further AUD-related degradation of the brain. In this narrative review, we 1) describe quantitative, controlled studies of brain macrostructure and microstructure of adults with AUD, 2) consider the possibility of recovery of brain integrity through harm reduction with sustained abstinence or reduced drinking, and 3) speculate on the ramifications of accelerated aging in AUD as contributing to age-related dementia.

Fetal demise and Wernicke-Korsakoff syndrome in a patient with hyperemesis gravidarum: a case report

BACKGROUND

Wernicke-Korsakoff syndrome is a neuropsychiatric disorder caused by thiamine deficiency composed of two related disorders accounting for an acute presentation and chronic progression. Hyperemesis gravidarum presents a significant risk factor for Wernicke-Korsakoff syndrome as symptoms may rapidly progress in the setting of pregnancy. We present the first-reported case of hyperemesis-gravidarum-associated Wernicke encephalopathy in a patient in the first half of pregnancy in which a missed diagnosis led to septic shock, fetal demise, and eventual profound Korsakoff syndrome.

CASE PRESENTATION

We present the case of a 33-year-old primigravid African American woman at 15 weeks gestational age who initially presented at a community emergency department with nausea and vomiting that ultimately progressed to severe hyperemesis-gravidarum-associated Wernicke-Korsakoff syndrome, fetal demise, and septic shock. The patient received a total of 6 weeks of high-dose parenteral thiamine. Magnetic resonance imaging of the head and formal neuropsychological assessment following treatment plateau confirmed the diagnosis of Wernicke-Korsakoff syndrome.

CONCLUSIONS

The multisystem complications seen in severe thiamine deficiency can delay timely administration of high-dose thiamine, particularly in pregnancy, in which the classic triad of Wernicke-Korsakoff syndrome may not raise clinical suspicion due to rapid progression of neurological sequelae in this population. We advise a low threshold for parenteral thiamine repletion in pregnant women with persistent vomiting as hyperemesis gravidarum-induced severe thiamine deficiency can result in Wernicke-Korsakoff syndrome, sepsis, and fetal demise.

Structural brain substrates of the deficits observed on the BEARNI test in alcohol use disorder and Korsakoff's syndrome

Chronic and excessive alcohol consumption can result in alcohol use disorder (AUD) without neurological complications and in Korsakoff's syndrome (KS) when combined with thiamine deficiency. These two clinical forms are accompanied by widespread structural brain damage in both the fronto-cerebellar (FCC) and Papez circuits (PC) as well as in the parietal cortex, resulting in cognitive and motor deficits. BEARNI is a screening tool especially designed to detect neuropsychological impairments in AUD. However, the sensitivity of this tool to the structural brain damage of AUD and KS patients remains unknown. Eighteen KS patients, 47 AUD patients and 27 healthy controls (HC) underwent the BEARNI test and a 3 T-MRI examination. Multiple regression analyses conducted between GM density and performance on each BEARNI subtest revealed correlations with regions included in the FCC, PC, thalamus and posterior cortex (precuneus and calcarine regions). All these brain regions were altered in KS compared to HC, in agreement with the cognitive deficits observed in the corresponding BEARNI subtests. The comparison between KS and AUD regarding the GM density in the several nodes of the FCC and calcarine regions revealed that they were atrophied to the same extent, suggesting that BEARNI is sensitive to the severity of alcohol-related GM abnormalities. Within the PC, the density of the cingulate cortex and thalamus, which correlated with the memory and fluency subscores, was smaller in KS than in AUD, suggesting that BEARNI is sensitive to specific brain abnormalities occurring in KS.

Case Report: Wernicke's encephalopathy after gastric surgery presenting as lactic acidosis and refractory thrombocytopenia

Wernicke's encephalopathy (WE) is a severe neuropsychiatric disorder, mainly resulting from a nutritional deficiency of thiamine. WE is hard to detect at an early stage. Less than 20% of WE can be diagnosed during a patient's lifetime, and WE tends to occur in patients with chronic alcoholism. Therefore, a large proportion of non-alcoholic WE patients are misdiagnosed. Lactate is an important by-product of anaerobic metabolism when the aerobic metabolism is blocked without thiamine, which can potentially serve as an alerting index for WE. Here, we report a case of a patient with WE who suffered gastric outlet obstruction following postoperative fasting, accompanied by lactic acidosis and refractory thrombocytopenia. A 67-year-old non-alcoholic woman who suffered hyperemesis for 2 months was diagnosed with gastric outlet obstruction (GOO). Gastric biopsies with endoscopy revealed gastric cancer, and total gastrectomy, together with D2 nodal dissection, was performed. She developed a coma with refractory thrombocytopenia rapidly after the surgical procedures were performed. The above conditions were treated not by the administration of antibiotics but by that of thiamine. We also found before the start of the procedures that she had a high level of blood lactate for a long period of time. Early diagnosis of WE is important because permanent injury can be caused to the central nervous system. Even today, the diagnosis of WE mainly depends on clinical symptoms, but occasionally, a typical triad occurs among WE patients. Therefore, a sensitive index for early diagnosis is critical for WE. Rising levels of blood lactate as a result of thiamine deficiency can serve as a warning for WE. In addition, we noted that this patient had a non-typical thiamine-sensitive refractory thrombocytopenia.

Diencephalic versus Hippocampal Amnesia in Alzheimer's Disease: The Possible Confabulation-Misidentification Phenotype

BACKGROUND

Alzheimer's disease (AD) is clinically heterogeneous, including the classical-amnesic (CA-) phenotype and some variants.

OBJECTIVE

We aim to describe a further presentation we (re)named confabulation-misidentification (CM-) phenotype.

METHODS

We performed a retrospective longitudinal case-series study of 17 AD outpatients with the possible CM-phenotype (CM-ADs). Then, in a cross-sectional study, we compared the CM-ADs to a sample of 30 AD patients with the CA-phenotype (CA-ADs). The primary outcome was the frequency of cognitive and behavioral features. Data were analyzed as differences in percentage by non-parametric Chi Square and mean differences by parametric T-test.

RESULTS

Anterograde amnesia (100%) with early confabulation (88.2%), disorientation (88.2%) and non-infrequently retrograde amnesia (64.7%) associated with reduced insight (88.2%), moderate prefrontal executive impairment (94.1%) and attention deficits (82.3%) dominated the CM-phenotype. Neuropsychiatric features with striking misidentification (52.9%), other less-structured delusions (70.6%), and brief hallucinations (64.7%) were present. Marked behavioral disturbances were present early in some patients and very common at later stages. At the baseline, the CM-ADs showed more confabulation (p < 0.001), temporal disorientation (p < 0.02), misidentification (p = 0.013), other delusions (p = 0.002), and logorrhea (p = 0.004) than the CA-ADs. In addition, more social disinhibition (p = 0.018), reduction of insight (p = 0.029), and hallucination (p = 0.03) persisted at 12 months from baseline. Both the CA- and CM-ADs showed anterior and medial temporal atrophy. Compared to HCs, the CM-ADs showed more right fronto-insular atrophy, while the CA-ADs showed more dorsal parietal, precuneus, and right parietal atrophy.

CONCLUSION

We described an AD phenotype resembling diencephalic rather than hippocampal amnesia and overlapping the past-century description of presbyophrenia.

Substance abuse and susceptibility to false memory formation: a systematic review and meta-analysis

Background

Substance abuse has an impact on various cognitive domains, including memory. Even though this impact has been extensively examined across different subdomains, false memory has been sparsely studied. This systematic review and meta-analysis seek to synthesize the current scientific data concerning false memory formation in individuals with a history of substance abuse.

Methods

PubMed, Scopus, the Cochrane Library, Web of Science, and PsycINFO were searched to identify all experimental and observational studies in English, Portuguese, and Spanish. Studies were then examined by four independent reviewers and, if they met the inclusion criteria, assessed for their quality. The Cochrane Risk of Bias Tool for randomized controlled trials (RCT) and the Joanna Briggs Institute (JBI) critical appraisal checklists for quasi-experimental and analytic cross-sectional studies were used to assess the risk of bias.

Results

From the 443 screened studies, 27 (and two more from other sources) were considered eligible for full-text review. A final 18 studies were included in the present review. Of these, 10 were conducted with alcoholics or heavy drinkers, four focused on ecstasy/polydrug users, three were done with cannabis users and one focused on methadone maintenance patients with current cocaine dependence. Regarding false memory type, 15 studies focused on false recognition/recall, and three on provoked confabulation.

Conclusions

None but one of the studies considering false recognition/recall of critical lures found any significant differences between individuals with a history of substance abuse and healthy controls. However, most of the studies taking into account false recognition/recall of related and unrelated events found that individuals with a history of substance abuse showed significantly higher rates of false memories than controls. Future research should continue to consider different types of false memories as well as their potential association with relevant clinical variables.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266503, identifier: CRD42021266503.

Thiamine deficiency in pregnancy and lactation: implications and present perspectives

During pregnancy, many physiologic changes occur in order to accommodate fetal growth. These changes require an increase in many of the nutritional needs to prevent long-term consequences for both mother and the offspring. One of the main vitamins that are needed throughout the pregnancy is thiamine (vitamin B1) which is a water-soluble vitamin that plays an important role in many metabolic and physiologic processes in the human body. Thiamine deficiency during pregnancy can cause can have many cardiac, neurologic, and psychological effects on the mother. It can also dispose the fetus to gastrointestinal, pulmonological, cardiac, and neurologic conditions. This paper reviews the recently published literature about thiamine and its physiologic roles, thiamine deficiency in pregnancy, its prevalence, its impact on infants and subsequent consequences in them. This review also highlights the knowledge gaps within these topics.

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.

A Clinician's View of Wernicke-Korsakoff Syndrome

The purpose of this article is to improve recognition and treatment of Wernicke-Korsakoff syndrome. It is well known that Korsakoff syndrome is a chronic amnesia resulting from unrecognized or undertreated Wernicke encephalopathy and is caused by thiamine (vitamin B1) deficiency. The clinical presentation of thiamine deficiency includes loss of appetite, dizziness, tachycardia, and urinary bladder retention. These symptoms can be attributed to anticholinergic autonomic dysfunction, as well as confusion or delirium, which is part of the classic triad of Wernicke encephalopathy. Severe concomitant infections including sepsis of unknown origin are common during the Wernicke phase. These infections can be prodromal signs of severe thiamine deficiency, as has been shown in select case descriptions which present infections and lactic acidosis. The clinical symptoms of Wernicke delirium commonly arise within a few days before or during hospitalization and may occur as part of a refeeding syndrome. Wernicke encephalopathy is mostly related to alcohol addiction, but can also occur in other conditions, such as bariatric surgery, hyperemesis gravidarum, and anorexia nervosa. Alcohol related Wernicke encephalopathy may be identified by the presence of a delirium in malnourished alcoholic patients who have trouble walking. The onset of non-alcohol-related Wernicke encephalopathy is often characterized by vomiting, weight loss, and symptoms such as visual complaints due to optic neuropathy in thiamine deficiency. Regarding thiamine therapy, patients with hypomagnesemia may fail to respond to thiamine. This may especially be the case in the context of alcohol withdrawal or in adverse side effects of proton pump inhibitors combined with diuretics. Clinician awareness of the clinical significance of Wernicke delirium, urinary bladder retention, comorbid infections, refeeding syndrome, and hypomagnesemia may contribute to the recognition and treatment of the Wernicke-Korsakoff syndrome.

Alcohol Use Disorder and Its Comorbidity With HIV Infection Disrupts Anterior Cingulate Cortex Functional Connectivity

BACKGROUND

Individuals with alcohol use disorder (AUD) have a heightened risk of contracting HIV infection. The effects of these two diseases and their comorbidity on brain structure have been well described, but their effects on brain function have never been investigated at the scale of whole-brain connectomes.

METHODS

In contrast with prior studies that restricted analyses to specific brain networks or examined relatively small groups of participants, our analyses are based on whole-brain functional connectomes of 292 participants.

RESULTS

Relative to participants without AUD, the functional connectivity between the anterior cingulate cortex and orbitofrontal cortex was lower for participants with AUD. Compared with participants without AUD+HIV comorbidity, the functional connectivity between the anterior cingulate cortex and hippocampus was lower for the AUD+HIV participants. Compromised connectivity between these pairs was significantly correlated with greater total lifetime alcohol consumption; the effects of total lifetime alcohol consumption on executive functioning were significantly mediated by the functional connectivity between the pairs.

CONCLUSIONS

Taken together, our results suggest that the functional connectivity of the anterior cingulate cortex is disrupted in individuals with AUD alone and AUD with HIV infection comorbidity. Moreover, the affected connections are associated with deficits in executive functioning, including heightened impulsiveness.

Extrahepatic Manifestations in Alcoholic Liver Disease

Though liver is the most commonly affected organ in patients with chronic and excessive intake of alcohol, no organ is immune to toxic effects of alcohol and patients with alcohol-related liver disease (ALD) can suffer from a wide list of extrahepatic manifestations involving gastrointestinal tract, central and peripheral nervous systems, cardio vascular system, musculo-skeletal system, disruption of nutritional status, endocrinological abnormalities, hematological abnormalities and immune dysfunction. These extrahepatic organ involvements are usually overlooked by hepatologists and physicians who are mostly focused on managing life threatening complications of ALD. As a result, there is delayed diagnosis, delay in the initiation of appropriate treatment and late referral to other specialists. Some of these manifestations are of utmost clinical importance (e.g. delirium tremans and Wernicke's encephalopathy) because an early diagnosis and treatment can lead to full recovery while delayed or no treatment can result in death. On the other hand, several extrahepatic manifestations are of prognostic significance (such as alcoholic cardiomyopathy and malignancies) in which there is an increased risk of morbidity and mortality. Hence, a clear understanding and awareness of the extrahepatic manifestations of ALD is quintessential for proper management of these patients.

SLC19A1 Genetic Variation Leads to Altered Thiamine Diphosphate Transport: Implications for the Risk of Developing Wernicke-Korsakoff's Syndrome

AIMS

Wernicke-Korsakoff syndrome (WKS) is commonly associated with chronic alcohol misuse, a condition known to have multiple detrimental effects on thiamine metabolism. This study was conducted to identify genetic variants that may contribute to the development of WKS in individuals with alcohol dependence syndrome through alteration of thiamine transport into cells.

METHODS

Exome sequencing data from a panel of genes related to alcohol metabolism and thiamine pathways were analysed in a discovery cohort of 29 individuals with WKS to identify possible genetic risk variants associated with its development. Variant frequencies in this discovery cohort were compared with European frequencies in the Genome Aggregation Database browser, and those present at significantly higher frequencies were genotyped in an additional cohort of 87 alcohol-dependent cases with WKS and 197 alcohol-dependent cognitively intact controls.

RESULTS

Thirty non-synonymous variants were identified in the discovery cohort and, after filtering, 23 were taken forward and genotyped in the case-control cohort. Of these SLC19A1:rs1051266:G was nominally associated with WKS. SLC19A1 encodes the reduced folate carrier, a major transporter for physiological folate in plasma; rs1051266 is reported to impact folate transport. Thiamine pyrophosphate (TPP) efflux was significantly decreased in HEK293 cells, stably transfected with rs1051266:G, under thiamine deficient conditions when compared with the efflux from cells transfected with rs1051266:A (P = 5.7 × 10-11).

CONCLUSION

This study provides evidence for the role of genetic variation in the SLC19A1 gene, which may contribute to the development of WKS in vivo through modulation of TPP transport in cells.

Patients With Severe Alcohol-Related Cognitive Impairment Improve in Flexibility When Abstinence Is Maintained: A Comparative Study With Alzheimer’s Disease

The disease progression of severe alcohol-related cognitive impairment (ARCI) is debated. The aim of this study was to compare the cognitive change of patients with severe ARCI in inpatient setting to that of patients with Alzheimer’s disease (AD). Fifteen consecutive patients with severe ARCI were recruited between 2013 and 2015. They received inpatient detoxification, neurological assessment, and inpatient cognitive rehabilitation in specialized facilities. Twelve patients, with documented AD matched on sex and initial cognitive impairment severity, were selected. All have benefited from two neuropsychological assessments. The neurocognitive change was tested in both groups with pair-wised Wilcoxon tests. ARCI and AD patients’ time course was compared with Mann–Whitney–Wilcoxon test. In ARCI group, first assessment occurred at 2.9 (± 2.2) months of abstinence and follow-up 6.5 (± 2.9) months later, the mean age was 56.5 (± 7.4) years, and 12 were men. In AD group, follow-up occurred at 12.8 (± 2.9) months (p < 10–3), the mean age was 72.3 (± 8.4) years (p < 10–3), and 10 were men. ARCI patients significantly improved on one executive function test (TMT-B; p < 0.05), while AD patients have worsened memory subtests on Free-and-Cued-Selective-Reminding Test (p < 0.05). These tests showed a statistically different change between severe ARCI and AD group (p < 0.05). Severe ARCI patients have improved in executive functioning, discernible on the TMT-B test, in specific care setting, including abstinence maintenance and rehabilitation. The disease progression was different from that observed in AD patients.

What is the Korsakoff syndrome? - a paper in tribute to Prof Alwyn Lishman

INTRODUCTION

Alwyn Lishman was interested in how memory research could be applied to clinical psychiatry. After a brief review of his major contributions, this paper will focus on his research on the alcoholic Korsakoff syndrome. It will consider how his findings relate to contemporary debates, particularly on how the syndrome should be defined, and its relationship to broader alcohol-induced cognitive impairments.

METHODS

A review of the contribution of Alwyn Lishman, Robin Jacobson and colleagues to our knowledge of Korsakoff's syndrome, together with a review of the pertinent recent literature.

RESULTS

Lishman and colleagues followed earlier authors in defining the Korsakoff syndrome in terms of disproportionate memory impairment, but they also noted a variable degree of IQ, frontal-executive, and timed visuo-spatial impairment in their cases. More recent authors have included such features in their definitions of the syndrome. Lishman also argued for a specific "alcoholic dementia". The present paper argues that recent definitions of the Korsakoff syndrome confound its core and associated features, and also fail to recognise the multifactorial basis of alcohol-related brain damage.

CONCLUSIONS

Korsakoff's syndrome is best defined in terms of disproportionate memory impairment, and more widespread cognitive impairment is best encompassed within "alcohol-related brain damage".

What is the optimum thiamine dose to treat or prevent Wernicke's encephalopathy or Wernicke-Korsakoff syndrome? Results of a randomized controlled trial

Background

The primary cause of Wernicke–Korsakoff syndrome (WKS) is thiamine deficiency, and more than 90% of cases are reported in alcohol‐dependent patients. While observational studies show parenteral thiamine administration drastically reduced WKS‐related mortality, relevant treatment trials have never been conducted to determine the optimum thiamine dose.

Methods

Two double‐blind, parallel groups, randomized controlled trials (RCTs) were conducted to determine the optimal thiamine dose required for (1) the prevention of Wernicke's encephalopathy (WE), the acute phase of WKS, in asymptomatic but “at‐risk” alcohol misuse patients (Study 1) and (2) the treatment of WE in symptomatic alcohol misuse patients (Study 2). Each study had a dosage regimen comprising three parenteral thiamine doses that were allocated at a ratio of 1:1:1. Study 1: Asymptomatic At‐Risk patients (N = 393) received either 100 mg daily, 100 mg thrice daily, or 300 mg thrice daily, for 3 days. Study 2: Symptomatic patients (N = 127) received either 100 mg thrice daily, 300 mg thrice daily, or 500 mg thrice daily, for 5 days. Cognitive function was the primary outcome, assessed using the Rowland Universal Dementia Assessment Scale, two Cogstate subtests, and an adapted Story Memory Recall test. Secondary analyses examined differences in neurological function (ataxia, oculomotor abnormalities, and confusion) at follow‐up.

Results

No significant differences were observed between any of the dosage conditions for either Study 1 or Study 2 on cognition or neurological functioning. This real‐world study found that having a clinically unwell target population with high comorbidity and multiple presentations, coupled with challenges in cross‐cultural assessment is likely to complicate RCT findings.

Conclusions

The results of this study showed no clear benefit of high dose thiamine over intermediate or lower doses of thiamine, over the time intervals examined, for the treatment and prevention of cognitive and neurological abnormalities related to WKS. Several study limitations temper the interpretation of these findings. Nevertheless, the absence of conclusive evidence for the superiority of high‐dose thiamine supports a recommendation for patient‐specific treatment, while ensuring that the potential impact of other biochemical factors (e.g., magnesium and other B vitamin deficiencies) are considered and corrected if necessary.

Confabulations in post-acute and chronic alcoholic Korsakoff's syndrome: a cross-sectional study conducted in two centres

INTRODUCTION

Confabulations refer to the emergence of memories of experiences and events that are incorrect in place and time, or never took place. In alcoholic Korsakoff's syndrome, confabulations have been frequently reported, but seldomly been investigated. Traditional reports on confabulations state that confabulations in KS mainly occur in the post-acute phase of the illness. The aim of the study was to investigate whether confabulations extinguish in KS.

METHODS

An observational rating of confabulation behaviour (the NVCL-R) was completed for 172 KS patients with alcoholic KS. Post-acute and chronic KS patients were compared cross-sectionally in two centres.

RESULTS

Provoked and spontaneous confabulations were present in post-acute and chronic patients. Patients residing in a long-term care facility more often presented themselves with spontaneous confabulations than patients in a diagnostic centre.

CONCLUSIONS

In contrast to the traditional view, confabulations may be present throughout the course of KS, and are possibly more frequently present in patients receiving care in specialised long-term care facilities than in patients who receive less intensive support.Key pointsConfabulations are a central characteristic of Korsakoff's syndromeIn contrast to popular belief, confabulations may be present in acute and chronic Korsakoff's syndromeThe severity of confabulations is related to an unfavourable disease outcome in KSA longitudinal approach would help the confirmation of finding no decline in confabulations over time.

Preliminary construct validity of a memory concerns scale derived from a PROMIS® item bank in a spanish-speaking sample

This study examined preliminary evidence of construct validity in a stand-alone memory concerns scale constructed from the Patient-Reported Outcomes Measurement Information System (PROMIS®) Cognitive Function item bank. A sample of 396 individuals, ages 18-75 (M = 33.7, SD = 12.7), from Spain and Latin America completed an online survey regarding lifetime exposure to factors associated with neurological compromise. The sample was 69.4% female. Respondents completed 8 items from the PROMIS® Cognitive Function item bank v1.0 dealing with memory concerns (MCS-8) along with the PROMIS® 8-item short form reflecting general cognitive concerns (CCS-8). The MCS-8 had high internal consistency reliability (Cronbach's alpha = 0.90), and represented a factor distinct from general cognitive concerns items on the CCS-8 in confirmatory factor analysis. Analysis of covariance controlling for sex, age, and education, showed that individuals endorsing history of exposure to sources of neurological compromise scored significantly lower T-scores on the MCS-8 than those who did not report any such history, F(1,390) = 6.4, p = 0.012. Older age was significantly associated with greater memory concerns, a relationship with age not observed with the CCS-8. As a stand-alone self-report measure, the MCS-8 appears to measure a construct distinct from general cognitive concerns that may be of interest for further research in clinical populations.

Neurocognitive and substance use disorders in older adults: challenges and evidence

Purpose

This study aims to review the presentation of substance use disorders in older adults, how addiction intertwines with neurocognitive disorders and how to approach this vulnerable population.

Design/methodology/approach

Electronic data searches of PubMed, Medline and the Cochrane Library (years 2000–2021) were performed using the keywords “neurocognitive,” “dementia,” “substance use,” “addiction,” “older adults” and “elderly.” The authors, in consensus, selected pivotal studies and conducted a narrative synthesis of the findings.

Findings

Research about substance use disorders in older adults is limited, especially in those with superimposed neurocognitive disorders. Having dual diagnoses can make the identification and treatment of either condition challenging. Management should use a holistic multidisciplinary approach that involves medical professionals and caregivers.

Originality/value

This review highlights some of the intertwining aspects between substance use disorders and neurocognitive disorders in older adults. It provides a comprehensive summary of the available evidence on treatment in this population.

Anterior thalamic glutamatergic neurons modulate prefrontal cortical firing and regularity

For several decades, studies on learning and memory focused extensively on the neural circuitry between the hippocampus and the prefrontal cortex, with minimal attention to the role of the anterior thalamic nucleus (ATN). The diencephalic nucleus is rich in excitatory glutamate neurons that project to both the hippocampus and medial prefrontal cortex (mPFC). Neural projections from the hippocampus and mPFC have also been identified in the ATN through reciprocal circuits. Although ATN lesioning leads to memory loss (amnesia), the role of the ATN in the propagation of cognitive processes in the mPFC is still poorly understood. In the current study, we employed adeno-associated viral labeling and in vivo electrophysiology to trace ATN glutamate neural projections in the layers of the mPFC. Neuroanatomical mapping of ATN Vglut2⁺ projections revealed a topographic gradient in the infralimbic cortex (IL), prelimbic cortex (PrL), and cingulate cortex (Cg1). Specifically, the IL has the least ATN Vglut2⁺ terminals while the PrL (layer III) and Cg1 (layers III, Va/b, VI) have robust innervation. Functional tracing of the thalamocortical projection was performed by combining extracellular Cg1 and ATN recording with ATN Vglut2⁺ neuron photostimulation. Our results show that light-activated ATN Vglut2⁺ neurons drive Cg1 neural activity and increase the firing rate of putative pyramidal neurons in anesthetized mice. In addition, light-activated Cg1 putative neurons were characterized by a significant increase in firing regularity when compared with baseline response. Together, our results show that ATN Vglut2⁺ neurons modulate the firing rate and firing regularity of the putative Cg1 putative pyramidal cells, thus, creating a premise for direct influence on cognitive processes in cortical networks.

Smartwatch reminders are as effective as verbal reminders in patients with Korsakoff's syndrome: three case studies

Korsakoff's syndrome (KS) is a neurocognitive disorder caused by severe malnutrition. KS patients typically show severe impairments in prospective memory (PM), thus, have difficulties with remembering to perform delayed intentions. The current study investigated the possible benefits of a smartwatch aid for PM tasks in patients with KS and compared its efficacy with verbal in-person reminders. Three patients participated in the present study and were asked to complete everyday PM tasks. The results of each patient were analyzed as a single-case study. The results highlight the great potential of using smartwatches as external memory aids in KS patients in everyday life.

Biological Properties of Vitamins of the B-Complex, Part 1: Vitamins B1, B2, B3, and B5

This review summarizes the current knowledge on essential vitamins B1, B2, B3, and B5. These B-complex vitamins must be taken from diet, with the exception of vitamin B3, that can also be synthetized from amino acid tryptophan. All of these vitamins are water soluble, which determines their main properties, namely: they are partly lost when food is washed or boiled since they migrate to the water; the requirement of membrane transporters for their permeation into the cells; and their safety since any excess is rapidly eliminated via the kidney. The therapeutic use of B-complex vitamins is mostly limited to hypovitaminoses or similar conditions, but, as they are generally very safe, they have also been examined in other pathological conditions. Nicotinic acid, a form of vitamin B3, is the only exception because it is a known hypolipidemic agent in gram doses. The article also sums up: (i) the current methods for detection of the vitamins of the B-complex in biological fluids; (ii) the food and other sources of these vitamins including the effect of common processing and storage methods on their content; and (iii) their physiological function.

"Vascular" Korsakoff Syndrome With Bilaterally Damaged Mammillothalamic Tracts: Insights Into the Pathogenesis of "Acute" Korsakoff Syndrome As Acute-Onset Irreversible Anterograde Amnesia

The structural pathogenesis of Wernicke-Korsakoff syndrome remains debatable. Wernicke encephalopathy is acute and often reversible whereas Korsakoff syndrome (KS) is chronic and may be irreversible. The cognitive deficits observed in KS are considered to be primarily due to damage to the anterior nucleus of the thalamus, mammillary bodies, and corpus callosum. We present an extremely rare case of non-alcoholic “vascular” KS (vKS) as acute-onset amnesia. A 97-year-old man living alone was brought to our hospital, complaining of sudden-onset behavioral changes with amnesia. Diffusion-weighted images (DWIs) showed fresh cerebral infarction in the right thalamus involving the right mammillothalamic tract (MTT). T2*-weighted images (T2*WIs), in addition, revealed a microbleed scar over the left MTT. This case supports the hypothesis that bilateral MTT dysfunction can lead to KS. Furthermore, in collaboration with a prior report about non-alcoholic “acute” KS due to cerebral infarction, this case supports the existence of vascular KS as an acute-onset amnestic syndrome, as well as insight into the pathogenesis of KS as an irreversible amnestic syndrome.

A Case of Chronic Wernicke Encephalopathy (WE): An Underdiagnosed Phenomena

Wernicke encephalopathy (WE) is the most common neurological complication of thiamine deficiency in patients who have a background of chronic alcohol use disorder. WE is characterized by acute onset of confusion, gait ataxia, and oculomotor dysfunction. Prompt treatment with parenteral thiamine leads to improvement. Untreated WE has mortality rates of up to 20% and many cases progress to the more chronic Korsakoff syndrome. Cases of untreated WE in which symptoms last beyond the acute phase and become chronic are rarely found in the literature. Here, we present a case of a 64-year-old female having a background of chronic alcohol use disorder presenting with symptoms of gait ataxia, recurrent falls, and decreased concentration. These symptoms had progressed over a period of nine months. The patient was seen by her family physician and several specialists undergoing many diagnostic studies with inconclusive results. Ultimately, with a high index of suspicion for thiamine deficiency, she was admitted for IV thiamine treatment. Upon follow-up in the clinic, the patient reported improvement in her balance and concentration further confirming the initial suspicion of WE with thiamine deficiency as the cause of her symptoms. This case corroborates the existence of WE as a chronic phenomenon in addition to the more commonly reported acute WE. Furthermore, this case highlights the importance of recognizing WE as a potential cause of chronic neurological symptoms in people with alcohol-related disorders and the role of IV thiamine in treatment.

Memory Dysfunction

PURPOSE OF THE REVIEW

This article provides a practical overview of the diagnostic process for patients with memory dysfunction through exploration of the anatomic, physiologic, and psychological aspects of human memory.

RECENT FINDINGS

As updated methods become available to neurologists, the ability to accurately identify and treat patients with memory disorders evolves. An appreciation of current concepts in the anatomic, physiologic, and psychological aspects of memory, combined with a rational application of everyday tools (such as clinical examination, bedside testing, standardized cognitive screening, and formal neuropsychological examination), allows the clinician to identify possible etiologies and track longitudinal changes in functional memory status. Recent findings regarding the interactions of limbic, anterior temporal, primary sensory, parietal, and dorsal prefrontal structures shed new light on the putative classifications of procedural and declarative memory and their subfunctions.

SUMMARY

An understanding of memory profiles pertaining to registration, encoding, consolidation, storage, and retrieval, as well as methods to assess those functions, facilitates the clinician's identification of underlying pathology and affected cerebral territories. The memory profile must be appreciated in the context of the entire individual, including possible confounds of comorbid conditions, psychiatric disorders, and normal healthy aging.

The specificity of thalamic alterations in Korsakoff's syndrome: Implications for the study of amnesia

The pathophysiological mechanisms behind amnesia are still unknown. Recent literature, through the study of patients with Alcohol Use Disorder with and without Korsakoff's syndrome, increasingly shows that physiological alterations to the thalamus have an important role in the development of amnesia. This review gives an overview of neuropsychological, neuropathological and neuroimaging contributions to the understanding of Korsakoff's syndrome, highlighting the central role of the thalamus in this amnesia. The thalamus being a multi-nucleus structure, the limitations regarding the loci, nature and alterations to specific nuclei are discussed, along with potential solutions. Finally, future directions for clinical research are laid out to unravel the intricacies inherent to amnesia. They consider the need to evaluate the physiological role of the thalamus, not only as an entity but also as part of a brain circuit through a more integrative approach.

Comprehensive neuropsychological findings in a case of Marchiafava-Bignami disease

OBJECTIVE

Marchiafava-Bignami disease (MBD) is a rare complication associated with chronic heavy alcohol use, with case reports documenting a range of cognitive outcomes. Given the variability in MBD presentation and outcomes, milder cases may remain undiagnosed and few studies or case reports have presented a comprehensive neuropsychological profile of these patients. The objective of this case study was to describe the neuropsychological presentation and findings of a case of likely MBD.

METHOD

The patient was a 46-year-old, African American female with a complex history of malnutrition and alcohol abuse presenting for outpatient neuropsychological evaluation. She was administered a comprehensive battery of neuropsychological tests as part of routine clinical care.

RESULTS

Neuropsychological data demonstrated severe deficits in executive functions, complex visuoconstruction, and motor dexterity, as well as an amnestic verbal and visual memory pattern.

CONCLUSIONS

Overall, data and the patient's initial presentation of acute behavioral change were consistent with some reports of cognitive and behavioral sequela of MBD. Additionally, the patient's history of chronic poor nutritional intake with exacerbation from chronic heavy alcohol use, and imaging findings of severe cerebral/corpus callosum white matter loss and bilateral frontoparietal atrophy, were highly suggestive of MBD.