Wernicke-Korsakoff Syndrome

I was recently assigned a patient diagnosed with Wernicke-Korsakoff Syndrome and discovered I needed a mini refresher on the condition. Read on to find out what I learned about this potentially fatal condition.

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Wernicke-Korsakoff Syndrome

I was recently assigned a patient with a history of alcohol abuse who was admitted to the hospital with a diagnosis of Wernicke-Korsakoff syndrome (WKS).  My knowledge of WKS was limited, so I prepared to care for this patient by conducting a mini knowledge brush-up.  I want to share some of what I learned.

What is WKS?

Wernicke-Korsakoff syndrome, also known as "wet brain" or alcohol-related dementia is caused by thiamine deficiency. The syndrome is a combination of 2 separate conditions, Wernicke's encephalopathy, and Korsakoff syndrome.  The most common cause of WKS is long-term heavy alcohol use.  Alcoholics are often deficient in thiamine (B1) because of:

  • Poor eating habits
  • Frequent vomiting
  • Inflamed stomach lining
  • Decreased ability to absorb vitamins in food

But WKS can also be caused by other conditions that lower thiamine levels. These causes may include:

  • Bariatric surgery
  • Colon surgery
  • Gastric cancer
  • Eating disorders
  • Chronic vomiting
  • Stomach disorders
  • Kidney disorders
  • Intestinal disorders
  • Malabsorption disorders
  • Chronic infection
  • Metastatic cancer

Incidence

WKS occurs in 1-2 percent of the U.S. population.  However, the percentage may be higher because WKS is not always detected by healthcare providers. Males carry a slightly higher risk, and the condition occurs evenly in people between the ages of 30-70.

Wernicke's Encephalopathy

Wernicke's encephalopathy (WE) is a neuropsychiatric disorder and usually occurs first in WKS.  Symptoms can present suddenly, sometimes progressing in just hours.  Wernicke's requires immediate medical intervention, but the symptoms are frequently missed or misdiagnosed.  It's often assumed the patient's behavior and physical symptoms are simply related to alcohol intoxication.  Symptoms of WE may include:

  • Confusion about place, time
  • Drowsiness
  • Loss of muscle coordination
  • Poor balance or difficulty walking
  • Leg numbness or tingling
  • Vision changes, such as double vision, eyelid drooping
  • Involuntary eye movements or paralysis of eye muscles
  • Memory gaps and poor memory recall

If treatment is not given in time, irreversible brain damage or even death may occur.

Diagnosis

A clinical diagnosis of WE in alcoholics requires two of the following four signs to be present:

  • Dietary deficiencies
  • Eye/visual problems
  • Cerebellar dysfunction, such as
  • Vertigo
  • Balance problems
  • Uncoordinated movements
  • Problems with speech
  • Altered mental status
  • Mild memory impairment

Diagnostic tests, such as labs and radiographic studies, are important in ruling out other potential causes for the patient's symptoms.

Treatment 

The goal of treatment is to quickly correct the B1 deficiency with intravenous or intramuscular administration of thiamine.

WE Prognosis

If left untreated, Wernicke's encephalopathy can lead to permanent brain damage and death.  However, the condition may be reversed with early diagnosis and treatment.  Once thiamine is administered, some symptoms begin to improve within hours.  Memory impairments are slower to improve and often do not return the patient's baseline.  

Around 80 to 90 percent of people who develop Wernicke's encephalopathy go on to develop Korsakoff's psychosis.

Korsakoff Syndrome

Korsakoff syndrome is the chronic stage of WKS and can be long-lasting.   Nerve cells in the brain and spinal cord are damaged, resulting in severe cognitive and memory deficits and difficulty performing day-to-day tasks. Other symptoms include:

  • Amnesia
  • Tremor
  • Coma
  • Disorientation  
  • Vision problems
  • Personality changes
  • Confabulation

Research has suggested around 25% of patients with Korsakoff syndrome recover fully, about 50% make a partial recovery, and 25% experience no change in their condition.

Wernicke-Korsakoff Syndrome 

As in WE, diagnostic tests are important in ruling out other potential causes for an accurate WKS diagnosis.

The following diagnostics are used to diagnose WKS:

Blood tests for:

  • Thiamine levels
  • Liver function
  • Kidney function
  • Brain imaging
  • Eye exam
  • Mental health exam
  • Tests to assess the brain and nervous system
  • Gait and ambulation tests

Treatment 

WKS usually requires hospitalization, administration of IV thiamine and management of symptoms.  Thiamine therapy also treats some common symptoms, such as vision, eye problems and confusion/disorientation.

Prognosis

All of the symptoms of WKS are not always reversible but the progression of the syndrome can be prevented if thiamine levels remain stable.  This requires abstinence from alcohol, a balanced diet and treatment of other underlying medical problems. Some patients will require physical and/or occupational therapy to help them become as independent as possible in their daily life.  The condition is fatal if left untreated.

What conditions or topics do you need to brush up on your knowledge?

References

Wernicke-Korsakoff Syndrome Information Page

What is Wernicke-Korsakoff Syndrome?

Wernicke-Korsakoff Syndrome 

CDC Alcohol Fact Sheets- Alcohol Use and Your Health

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J.Adderton

About J.Adderton, BSN, MSN

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I am a nurse with over 25 years experience and living day-by-day in these uncharted waters. I am grateful for the nursing community and continue to be inspired by the profession's contribution toward better days.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Thank you for your research and information! I know that in our intensive care unit we have many alcoholics admitted or upgraded in care as they progress through a variety of symptoms. One of the problems is that with the exception of lab values, our assessment of many of the associated symptoms of these conditions is hampered by medications being administered to try to keep the patients safe. Once they're on ativan, librium, versed, phenobarbitol, precedex, or the like- we can rarely assess aspects like balance and coordination, vision problems, eye exams, because they are sedated to the point that they cannot follow directions or provide coherent conversation. 

We are finding that in the past few months, the general acuity of many of the patients admitted for conditions related to alcohol intake has increased greatly. Since people are not going out or getting together, many of these patients have been isolated and unfortunately, many have died because their disease has progress beyond our ability to treat. Most often fulminant liver failure has developed and they don't leave the hospital alive. 

I appreciate you sharing the information!

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I’m a baby nurse of 2 years, and I’m thrilled to have this forum where I can learn so much from those with lots of experience.

Not only did you teach me about WKS, but you introduced me to the symptom name “confabulation” - “a symptom of various brain disorders in which made-up stories fill in any gaps in memory...often described as ‘honest lying.”   Great word!

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Specializes in Psych (25 years), Medical (15 years).
4 hours ago, JBMmom said:

Once they're on ativan, librium, versed, phenobarbitol, precedex, or the like-

The like being Serax (oxazepam)? as it is not metabolised via the liver as the other benzodiazepines. Serax is metabolised chiefly through the kidneys.

The medical director of the CD treatment program where I worked back in the '80's would lean toward prescribing Serax during detox, since the liver was already overworked.

Excellent article, J.Adderton!

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This is the underlying reason we kind of got off track and were giving banana bags/rally packs to seemingly every intoxicated patient for awhile.

Some interesting reading:

https://www.aliem.com/mythbusting-banana-bag/

http://www.emdocs.net/thiamine-deficiency-pearls-pitfalls/

There's lots of info out there, I just picked these two

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Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.

Great information!

Thanks!

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Specializes in ICU.

This is a great post, thank you for sharing!

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Specializes in Mental health, substance abuse, geriatrics, PCU.

Excellent article. In my area it is a standard of care to give either IM or IV thiamine to alcoholics when they come through the ER, if they are admitted either medically or psychiatrically they're started on PO thiamine and folic acid for the duration of their admission. One psych unit I worked on gave IM thiamine to every alcohol detox admission even if they had received thiamine in the ER just to be on the safe side. 

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Specializes in ICU.
57 minutes ago, TheMoonisMyLantern said:

Excellent article. In my area it is a standard of care to give either IM or IV thiamine to alcoholics when they come through the ER, if they are admitted either medically or psychiatrically they're started on PO thiamine and folic acid for the duration of their admission. One psych unit I worked on gave IM thiamine to every alcohol detox admission even if they had received thiamine in the ER just to be on the safe side. 

I was going to say something about that, too, in my ICU we give thiamine to anyone with a heavy alcohol history. Even if they don’t drink heavily anymore we still do it in case they downplay how much they drink now.

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Specializes in Clinical Leadership, Staff Development, Education.
On 1/8/2021 at 8:28 AM, JBMmom said:

 

We are finding that in the past few months, the general acuity of many of the patients admitted for conditions related to alcohol intake has increased greatly.

I've been sober for almost 5 years and don't think I would have lived through pandemic. I think I would have several episodes of alcohol poisoning.  I thought ICUs  must be caring for more alcohol and drug related illnesses.

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Specializes in Clinical Leadership, Staff Development, Education.
On 1/8/2021 at 1:03 PM, JKL33 said:

Some interesting reading:

https://www.aliem.com/mythbusting-banana-bag/

http://www.emdocs.net/thiamine-deficiency-pearls-pitfalls/

There's lots of info out there, I just picked these two

These are great and I am all about clinical pearls!  thanks for sharing.

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Specializes in Clinical Leadership, Staff Development, Education.
On 1/8/2021 at 8:52 AM, Brownelfin said:

Not only did you teach me about WKS, but you introduced me to the symptom name “confabulation” - “a symptom of various brain disorders in which made-up stories fill in any gaps in memory...often described as ‘honest lying.”   Great word!

I actually had to look up what confabulation meant.  It's interesting how many pts I have had that used it.

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