eMedicine Specialties > Psychiatry > Adult

Wernicke-Korsakoff Syndrome: Follow-up

Author: Glen L Xiong, MD, Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic
Coauthor(s): G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center; Alan DeAngelo, MD, Consulting Staff, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Dwight David Eisenhower Army Medical Center; Alan W Halliday, MD, Chief of Neurology Service, Brooke Army Medical Center; Clinical Professor, Department of Neurology, University of Texas Health Science Center at San Antonio; Associate Professor of Neurology, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: May 29, 2008

Follow-up

Further Inpatient Care

Evaluation for progression or recovery from Wernicke-Korsakoff syndrome symptom complex is the primary reason for further inpatient care. Patients also require monitoring for alcohol withdrawal and the potential cardiac manifestations of Wernicke-Korsakoff syndrome (eg, congestive heart failure).

Further Outpatient Care

  • Recovering patients will require outpatient follow-up care to evaluate for continued progress or relapse.
  • Patients with long-term alcoholism may benefit from further inpatient or outpatient rehabilitation, depending on the likelihood of compliance.

Inpatient & Outpatient Medications

Patients should continue taking thiamine supplementation, as well as other vitamins and electrolytes, until a well-balanced diet can be maintained. Long-term supplementation may be required in patients who cannot maintain adequate nutritional intake, whether from noncompliance or the underlying disorder.

Deterrence/Prevention

  • Long-term alcohol use is the most common etiology for development of Wernicke-Korsakoff syndrome. Abstinence from alcohol provides the best chance for recovery, in conjunction with thiamine replacement. Refer patients for alcohol abuse counseling, community alcohol abuse treatment programs (eg, alcoholics anonymous and other consumer support programs), and couples/family therapy, on an individual basis to deter future use and prevent future episodes. Also, see Medscape's CME course, Video Cases From NIAAA: Helping Patients Who Drink Too Much.
  • In patients at risk for malnutrition (eg, after gastric bypass surgery), appropriate thiamine and other B vitamin supplementation should be taken with the advice of a nutritionist.    
  • In emergency management of patients with acute confusion and concurrent risk factors (eg, alcohol dependence and malnutrition), thiamine administration should be highly considered, especially prior to glucose administration.19  Generally, high carbohydrate diets increase the demand for thiamine.3
  • In a large prospective study, the introduction of thiamine enriched bread flour was shown to reduce the prevalence of Wernicke-Korsakoff syndrome in Australia.20  However, whether thiamine fortification in general or additional supplementation in alcoholic beverages could reduce Wernicke-Korsakoff syndrome has not been systematically studied. 

Complications

  • Ocular complications
    • Patients who recover generally do so in a particular sequence. Improvement of ocular abnormalities is the earliest and most dramatic, usually occurring within hours of the initial thiamine dose. Failure of ocular abnormalities to respond to thiamine in this manner should raise doubt as to the veracity of the diagnosis.
    • Vertical nystagmus may persist for months. Fine horizontal nystagmus may persist indefinitely in as many as 60% of patients, but patients completely recover from sixth nerve palsies, ptosis, and vertical gaze palsies.
  • Ataxic complications
    • Approximately 40% of patients recover completely from their ataxic symptoms. The remainder have varying degrees of incomplete recovery, with a residual slow, shuffling, wide-based gait and the inability to tandem walk.
    • Vestibular dysfunction generally responds to a similar degree.
  • Mental status complications: The symptoms of global confusional state often resolve gradually after treatment is initiated. If an amnestic deficit is present, it will manifest as the early signs of apathy and global confusion resolve. Only 20% of patients who demonstrate signs of the amnestic state after treatment has been initiated have complete recovery. The remaining patients have varying degrees of persistent learning and memory impairment. Maximum recovery may take 1 or more years and depends on abstinence from alcohol. According to reports, once patients with Korsakoff psychosis have recovered, they do not demand alcohol, but they will accept it if offered.

Prognosis

  • Mortality may be secondary to infections and hepatic failure, but some deaths are directly attributable to irreversible defects of severe and prolonged thiamine deficiency (eg, coma).

Patient Education

  • In alcohol-related Wernicke-Korsakoff syndrome, abstinence from alcohol and maintenance of a balanced diet offer the best chance for recovery and prevention of future episodes.
  • Patients who have undergone gastric bypass surgery are recommended to adhere to a balanced diet and continue vitamin supplementation.
  • Family education and support is an important component of taking care of anyone with a dementia illness, including Wernicke-Korsakoff syndrome. Patients with persistent dementia usually require 24-hour supervision because they usually have poor insight into their illness and significant functional impairments in activities of daily living. Some patients with alcohol dependence may continue to prefer alcohol use, despite their cognitive deficits. In severe cases, private or public guardianships (or conservatorships) may need to be sought from the courts. 
  • Some helpful web sites for patients include the following:

Miscellaneous

Medicolegal Pitfalls

  • Maintain a high level of suspicion for thiamine deficiency to avoid iatrogenic precipitation of Wernicke-Korsakoff syndrome. Heightened awareness should lead to prophylactic supplementation in at-risk patients.
    • This syndrome is most commonly observed in patients with alcoholism, so, when these patients present to an emergency department, they are routinely administered thiamine prior to glucose infusion.
    • Several other categories of patients are at increased risk for thiamine deficiency, including inpatients receiving total parental nutrition, which necessitates vigilant monitoring for indicative signs and symptoms to ensure prompt treatment.

Special Concerns

  • Alcohol use is the most common etiology for Wernicke-Korsakoff syndrome. Health care providers usually need to treat varying degrees of withdrawal symptoms in any patient who presents with Wernicke-Korsakoff syndrome.
 


More on Wernicke-Korsakoff Syndrome

Overview: Wernicke-Korsakoff Syndrome
Differential Diagnoses & Workup: Wernicke-Korsakoff Syndrome
Treatment & Medication: Wernicke-Korsakoff Syndrome
Follow-up: Wernicke-Korsakoff Syndrome
References
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References

  1. McEntee WJ, Mair RG. Memory enhancement in Korsakoff's psychosis by clonidine: further evidence for a noradrenergic deficit. Ann Neurol. May 1980;7(5):466-70. [Medline].

  2. Harper C, Fornes P, Duyckaerts C, Lecomte D, Hauw JJ. An international perspective on the prevalence of the Wernicke-Korsakoff syndrome. Metab Brain Dis. Mar 1995;10(1):17-24. [Medline].

  3. Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. May 2007;6(5):442-55. [Medline].

  4. Kesler A, Stolovitch C, Hoffmann C, Avni I, Morad Y. Acute ophthalmoplegia and nystagmus in infants fed a thiamine-deficient formula: an epidemic of Wernicke encephalopathy. J Neuroophthalmol. Sep 2005;25(3):169-72. [Medline].

  5. Chiossi G, Neri I, Cavazzuti M, Basso G, Facchinetti F. Hyperemesis gravidarum complicated by Wernicke encephalopathy: background, case report, and review of the literature. Obstet Gynecol Surv. Apr 2006;61(4):255-68. [Medline].

  6. Singh S, Kumar A. Wernicke encephalopathy after obesity surgery: a systematic review. Neurology. Mar 13 2007;68(11):807-11. [Medline].

  7. Alcaide ML, Jayaweera D, Espinoza L, Kolber M. Wernicke's encephalopathy in AIDS: a preventable cause of fatal neurological deficit. Int J STD AIDS. Oct 2003;14(10):712-3. [Medline].

  8. Harrison RA, Vu T, Hunter AJ. Wernicke's encephalopathy in a patient with schizophrenia. J Gen Intern Med. Dec 2006;21(12):C8-C11. [Medline].

  9. Yae S, Okuno S, Onishi H, Kawanishi C. Development of Wernicke encephalopathy in a terminally ill cancer patient consuming an adequate diet: a case report and review of the literature. Palliat Support Care. Dec 2005;3(4):333-5. [Medline].

  10. Ueda K, Takada D, Mii A, Tsuzuku Y, Saito SK, Kaneko T, et al. Severe thiamine deficiency resulted in Wernicke's encephalopathy in a chronic dialysis patient. Clin Exp Nephrol. Dec 2006;10(4):290-3. [Medline].

  11. Maschke M, Weber J, Bonnet U, Dimitrova A, Bohrenkamper J, Sturm S, et al. Vermal atrophy of alcoholics correlate with serum thiamine levels but not with dentate iron concentrations as estimated by MRI. J Neurol. Jun 2005;252(6):704-11. [Medline].

  12. Zuccoli G, Gallucci M, Capellades J, Regnicolo L, Tumiati B, Giadas TC, et al. Wernicke encephalopathy: MR findings at clinical presentation in twenty-six alcoholic and nonalcoholic patients. AJNR Am J Neuroradiol. Aug 2007;28(7):1328-31. [Medline].

  13. Fei GQ, Zhong C, Jin L, Wang J, Zhang Y, Zheng X, et al. Clinical characteristics and MR imaging features of nonalcoholic Wernicke encephalopathy. AJNR Am J Neuroradiol. Jan 2008;29(1):164-9. [Medline].

  14. Traviesa DC. Magnesium deficiency: a possible cause of thiamine refractoriness in Wernicke-Korsakoff encephalopathy. J Neurol Neurosurg Psychiatry. Aug 1974;37(8):959-62. [Medline].

  15. Day E, Bentham P, Callaghan R, Kuruvilla T, George S. Thiamine for Wernicke-Korsakoff Syndrome in people at risk from alcohol abuse. Cochrane Database Syst Rev. 2004;CD004033. [Medline].

  16. Cochrane M, Cochrane A, Jauhar P, Ashton E. Acetylcholinesterase inhibitors for the treatment of Wernicke-Korsakoff syndrome--three further cases show response to donepezil. Alcohol Alcohol. Mar-Apr 2005;40(2):151-4. [Medline].

  17. Rustembegovic A, Kundurovic Z, Sapcanin A, Sofic E. A placebo-controlled study of memantine (Ebixa) in dementia of Wernicke-Korsakoff syndrome. Med Arh. 2003;57(3):149-50. [Medline].

  18. Luykx HJ, Dorresteijn LD, Haffmans PM, Bonebakker A, Kerkmeer M, Hendriks VM. Rivastigmine in Wernicke-Korsakoff's syndrome: five patients with rivastigmine showed no more improvement than five patients without rivastigmine. Alcohol Alcohol. Jan-Feb 2008;43(1):70-2. [Medline].

  19. Hack JB, Hoffman RS. Thiamine before glucose to prevent Wernicke encephalopathy: examining the conventional wisdom. JAMA. Feb 25 1998;279(8):583-4. [Medline].

  20. Harper CG, Sheedy DL, Lara AI, Garrick TM, Hilton JM, Raisanen J. Prevalence of Wernicke-Korsakoff syndrome in Australia: has thiamine fortification made a difference?. Med J Aust. Jun 1 1998;168(11):542-5. [Medline].

  21. Adams RD, Victor M, Ropper AH. Diseases of the nervous system due to nutritional deficiency. In: Principles of Neurology. 6th ed. New York, NY: McGraw Hill Text; 1997:1138-1145.

  22. Al-Sanouri I, Dikin M, Soubani AO. Critical care aspects of alcohol abuse. South Med J. Mar 2005;98(3):372-81. [Medline].

  23. Berger JR. The neurological complications of bariatric surgery. Arch Neurol. Aug 2004;61(8):1185-9. [Medline].

  24. Blass JP, Gibson GE. Abnormality of a thiamine-requiring enzyme in patients with Wernicke-Korsakoff syndrome. N Engl J Med. Dec 22 1977;297(25):1367-70. [Medline].

  25. Diamond I. Nutritional disorders of the Nervous System. In: Cecil RL, Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 19th ed. Philadelphia, Pa: WB Saunders Co; 1992:2125-2128.

  26. Guerrini I, Thomson AD, Cook CC, McQuillin A, Sharma V, Kopelman M, et al. Direct genomic PCR sequencing of the high affinity thiamine transporter (SLC19A2) gene identifies three genetic variants in Wernicke Korsakoff syndrome (WKS). Am J Med Genet B Neuropsychiatr Genet. Aug 5 2005;137(1):17-9. [Medline].

  27. Iwata H. Possible role of thiamine in the nervous system. Trends Pharmacol Sci. 1982;4:171-173.

  28. Nautiyal A, Singh S, Alaimo DJ. Wernicke encephalopathy--an emerging trend after bariatric surgery. Am J Med. Nov 15 2004;117(10):804-5. [Medline].

  29. Reuler JB, Girard DE, Cooney TG. Current concepts. Wernicke's encephalopathy. N Engl J Med. Apr 18 1985;312(16):1035-9. [Medline].

  30. Rotman P, Hassin D, Mouallem M, Barkai G, Farfel Z. Wernicke's encephalopathy in hyperemesis gravidarum: association with abnormal liver function. Isr J Med Sci. Mar 1994;30(3):225-8. [Medline].

  31. Thomson AD, Marshall EJ. The natural history and pathophysiology of Wernicke's Encephalopathy and Korsakoff's Psychosis. Alcohol Alcohol. Mar-Apr 2006;41(2):151-8. [Medline].

  32. US Pharmacopeial Convention. Thiamine. In: Drug Information for the Health Care Professional. 18th ed. Micromedex; 1998:2824-2826. [Full Text].

  33. Victor M, Martin JB. Nutrional and metabolic diseases of the nervous system. In: Eugene Braunwald, ed. Harrison's Principles of Internal Medicine. 1994. 13th ed. New York, NY: McGraw Hill Text; 2328-2331.

  34. Zubaran C, Fernandes JG, Rodnight R. Wernicke-Korsakoff syndrome. Postgrad Med J. Jan 1997;73(855):27-31. [Medline].

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Further Reading

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Keywords

Wernicke-Korsakoff syndrome, Wernicke encephalopathy, Wernicke's encephalopathy, polioencephalitis hemorrhagica superioris, Korsakoff's psychosis, Korsakoff psychosis, amnestic-confabulatory state, psychosis polyneuritica, thiamine deficiency, confusion, ataxia, nystagmus, alcoholism, Korsakoff amnestic state, confabulation, Korsakoff dementia, nutritional deficiency

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Contributor Information and Disclosures

Author

Glen L Xiong, MD, Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic
Glen L Xiong, MD is a member of the following medical societies: American College of Physicians, American Psychiatric Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center
G Patrick Daubert, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Alan DeAngelo, MD, Consulting Staff, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Dwight David Eisenhower Army Medical Center
Alan DeAngelo, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Alan W Halliday, MD, Chief of Neurology Service, Brooke Army Medical Center; Clinical Professor, Department of Neurology, University of Texas Health Science Center at San Antonio; Associate Professor of Neurology, Uniformed Services University of the Health Sciences
Alan W Halliday, MD is a member of the following medical societies: American Academy of Neurology, Texas Medical Association, and Texas Neurological Society
Disclosure: Nothing to disclose.

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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