Advances in Psychiatric Treatment (1999), vol. 5, pp. 271-278

Managetnent of alcohol Korsakoffsyndrotne

lain Smith & Audrey Hillman

"Contrary to popular belief, partial recovery fromKorsakoff's Psychosis is the rule and 21% recovermore or less completely. However the extent to whichthe patient will recover cannot be predicted withconfidence during the acute stages of the illness. Failureto appreciate these facts about the natural history ofthe mental illness may result in the prematureconfinement of the patient to a mental hospital"(Victor et ai, 1971).

There is a commonly held view that the Korsakoffsyndrome (amnestic syndrome) is a static conditionand that, once detected, the main issue in manage­ment is suitable placement. However, any decisionon long-term placement has to be taken at the pointwhere the potential for further recovery is unlikelyand this requires regular and careful review of apatient's mental state during the first year afterpresentation. There is current concern from suchsources as the Mental Welfare Commission inScotland that patients may be moved at too early astage to residential care, without adequate psychi­atric review, and with poor understanding by theresidential or nursing home staff of the nature ofthis condition. Much of the current literature on thecondition focuses on aetiology or on the search fordrug treatments for the syndrome. There is very littleliterature on rehabilitation of individuals with thesyndrome in general psychiatric textbooks andjournals.

This paper aims to summarise the main medicaltreatment for Korsakoff syndrome and its complic­ations and to focus on issues of rehabilitation. Forall practical purposes we are discussing themanagementofalcohol Korsakoff syndrome (alcoholamnestic disorder), as cases of non-alcoholicKorsakoff syndrome of chronic duration areexceedingly rare.

The common association of the Wernicke­Korsakoff syndrome and alcohol dependencein Western societies is well described and anyconsideration of the management of these patientsmust include the need to promote abstinence fromalcohol and treat the alcohol dependence where thisseems possible.

The paper also aims to increase understanding ofthe spectrum of neuropsychological deficits in thisgroup and knowledge of prognostic indicators forrecovery from this disorder. The possible role ofrehabilitation psychiatry, a less-resourced specialityin the era of community care, is also discussed.

Definition of the Wernicke­Korsakoff syndrome

For a full outline of this syndrome, the reader isadvised to consult the classic research monographby Victor et al (1989), and two review articles in theBritish Journal of Psychiatry (Kopelman, 1995;Lishman, 1990) (see Box 1 for summary points).

Not all cases of Korsakoff syndrome are precededby an episode of Wernicke's encephalopathy.However, if during an episode of Wernicke'sencephalopathy (which is essentially a toxicconfusional state) a specific amnesic deficit isdetectable, then the condition is likely to proceed toa full Korsakoff syndrome and will respond slowly,if at all, to thiamine supplementation.

In its purest form, Korsakoff syndrome would bean example ofan amnestic syndrome, which impliesa specific deficit of recent memory with a relativelyintact remote memory and intellect. However, in

lain David Smith is a consultant psychiatrist and Honorary Clinical Senior Lecturer at Gartnavel Royal Hospital (1055 GreatWestern Road, Glasgow G12 OXH). He is a general psychiatrist with a special interest in alcohol and drug problems. Withresearch interest in the epidemiology of Korsakoff psychosis in Scotland, he has also collaborated in research into possiblegenetic influences in alcohol-related brain damage. Audrey Hillman is a consultant psychiatrist at Ravenscraig Hospital(Inverkip Road, Greenock, PA16 9HA). Also a general psychiatrist with a special interest in alcohol problems. she works in anarea where there is a high prevalence of alcohol-related brain damage and the local service is exploring the possibility ofdeveloping a unit specifically for this patient group.

APT(1999), vo/.S,p. 272 5111it1, & Hi//I/ltl/l

Bo 1. Kor akoff yndrome

Mo t commonly seen as an enduring com­plication of the alcohol dependenceyndrome

ot alway preceded by Wernicke's enceph­alopathy

Classically is an amnestic yndrome withimpaired recent memory and relativelyintact intellectual function

Can show varying degrees of recoveryDeficit are open to certain forms of rehabili­

tative intervention in order to maximisesocial function

practice, patients will present with a range offeatures from the pure amnestic syndrome througha mixed picture ofamnesia and additional cognitivedeficits through to alcohol dementia.

Inclinical practice, the terms Korsakoff syndromeand alcohol dementia are often used loosely andinterchangeably, perhaps reflecting some of thelimitations of bedside mental state examination,(Anonymous, 1987). Precise methods of assessmentto classify patients on dimensions of amnesia anddementia are therefore useful in that they may haveprognostic and therapeutic implications. This isthe opinion of Lishman (1990) who believes thatthese two dimensions may have differing aetiologiesand that in order to develop chronic Korsakoffsyndrome, the patient needs to have a combinationof thiamine depletion-induced and alcohol-inducedbrain damage with both sub-eortical and corticalpathologies.

Epidemiology

Within Scotland the proportion of patients withKorsakoff syndrome and alcoholic dementia inmedium- to long-stay psychiatric wards hasremained high during a period of progressive bedclosures and the trend towards community care. Theprevalence of the disorder varies across countries.The incidence of the disorder is increasing inScotland according to official returns from allhospitals on admissions to in-patient care and alsodirect ascertainment in general and psychiatrichospitals (Ramayya & Jauhar, 1997). This is alsotrue in some other European countries, such as TheNetherlands where a 2o-fold increase in admissionswith this diagnosis was found between 1970 and1990 (Kok, 1991). There is less published information

for England and Wales. There is debate in theliterature about the reason for this increase.Suggested reasons include increased per capitaconsumption of alcohol, decreased prescribingof prophylactic parenteral vitamins to 'at-riskalcoholics' in general medical and psychiatricsettings, and increased social isolation of alcohol­dependent individuals, resulting in increasedalcohol consumption and poorer diet (Price, 1985).

The literature suggests there are important genderdifferences in the presentation and outcome inKorsakoff syndrome. It would appear that womenare more vulnerable to developing this syndromeand that cases of Korsakoff syndrome are over­represented in females if the greater rates of alcoholdependence in men are accepted(Victor et aI, 1989).

In the Victor et al series, the age at onset in womenwas on average a decade earlier than in men.Average age of onset for women was in the fifthdecade. This is not reflected in other series and inparticular in psychiatric hospital populations. Thislatter finding may be biased, as younger women maybe more likely to be cared for by relatives or to havefewer behavioural difficulties associated with thecondition. There is a shorter drinking time beforedeveloping Korsakoff syndrome in women. In onestudy, the mean number of years ofheavy drinkingfor females was half that for males who developKorsakoff syndrome; 10 v. 21 years, respectively(Cutting, 1978).

Gender differences may influence the prognosisin a more complex way. In the series of 63 patientsstudied by Cutting (1978), there was a subgroup offemales who developed alcohol Korsakoff syndromea decade later than men. They tended to haveinsidiously developing Korsakoff syndrome andtheir recovery tended to be more complete. They alsoshowed a more global impairment of intellect andwere comparable to a group labelled 'alcoholdementia'. It would therefore appear that the rate ofdevelopment of the syndrome is an importantprognostic factor in conjunction with gender andage. Sudden onset cases with a dense and relativelypure amnestic syndrome seem to have a poorerprognosis than those with insidious onset and moreglobal impairment (see Box 2).

Assessment

These patients are often first encountered in generalhospital settings or in squalor at home. They arerarely referred directly to general psychiatry. Theysometimes present to old age psychiatrists or liaisonpsychiatry services. The Wernicke-Korsakoffsyndrome can be associated with an alcohol-

/\!collOll\orstlkotf Sl/lldrollll' . \PI (1999),1'01. J, p. 27.3

Box 2. Progno is in Korsakoff syndrome

Poorer in udden-on et than in in idiou ­onset ca es

B tter with more global cognitive impainnentthan in purer amnestic yndrome (pro­vided there is ab tinence from alcohol)

Appears better in non-alcoholic ca e ofWernicke-Kor akoff yndrome

Improved if abstinence from alcohol is main­tained in milder cases

withdrawal delirium in the initial stages (Victor etaI, 1989).

Acute assessment and management

Ideally, ifpatients are still showing signs of a globalconfusional state, they should be nursed in a generalmedical setting. The presence and severity of anamnestic syndrome may not be assessable until theacute brain syndrome has subsided. Some idea aboutprogress towards recovery can be made by regularreview of these patients every few days. Theclassical triad of Wernicke's encephalopathy(ataxia, ophthalmoplegia, confusion) may not bepresent. All toxically confused patients should haveWernicke's encephalopathy considered in theirdifferential diagnoses, and parenteral thiaminesupplementation should be part of the routinetreatment of toxic confusional states of unknownaetiology, as well as in patients with a definitealcohol-withdrawal delirium.

Intennediate assessmentand management

Once a toxic state has resolved and the patient isconsistently alert, a clearerpicture of the deficits maybe obtained. Several features are thought to berelevant to the development of Korsakoff syndromeand to its recovery.

It may be possible clinically to elucidate variousrelevant prognostic factors at this stage by carefulexamination of the patient and by obtaining acollateral history. The collateral history can giveinformation about the rate ofonset which may be ofprognostic significance.

Classically, the outcome from an episode ofKorsakoff syndrome falls roughly into'quarters'.Approximately 25% show no recovery, 25% slight,25% significant and the other 25% show completerecovery from the episode in relation to impairmentof recent memory.

At this point assessment needs to be directedtowards appropriate placement for rehabilitation.There is an argument for an intermediate admissionto appropriate medium-stay/ rehabilitation units fora more protracted period of assessment prior to finalplacement after any recovery has been maximised.This may involve a stay of up to one year.

Arrangements for rehabilitation placement willobviously vary according to local resources. This iscurrently the topic ofsome debate and resources maybe woefully inadequate in some areas of the country.There is no standard model of a Korsakoff rehab­ilitation service in use in the UK, although examplesexist elsewhere, such as Australia and TheNetherlands. There is also debate about whichagency is best placed to provide rehabilitation forthese patients. Agencies involved include theNational Health Service, social work, private (forprofit) and voluntary agencies. Different systemsmay work equally well, but there has been littleevaluation of these in practice; we found threestudies of relevance here.

One was of a series of 44 patients allocated tonursing homes or specialist sheltered Korsakoffaccommodation. Those allocated to nursing homesshowed more deterioration in social functioningcompared with those allocated to specialist accom­modation, although cognitive functioning was equalin both groups (Blansjaar et ai, 1992).

The second was a comparison of functioning ofpatients in ordinary long-stay psychiatric wardscompared with those in a specialist Korsakoffrehabilitation ward. At the end of a six-monthperiod, those in the specialised unit showed asignificantly greater improvement in the speed ofinformation-processing and improved socialbehaviour. These improvements were also demon­strated in a group ofpatients who were subsequentlytransferred from ordinary long-stay to the specialistunit (Ganzevles et ai, 1994).

The third study describes a dedicated in-patientservice for this patient group in Sydney, Australia.Of the 104 patients (93 men and 11 women) whounderwent a structured rehabilitation programme,51% were successfully placed in the communityat follow-up 1-2 years after leaving hospital. Ofthe 53 patients who were successfully placed,the majority were living in boarding houses withsupply of meals and a degree of supervision(Lennane,1986).

We would argue that regardless of where rehab­ilitation services are provided, it is essential forpsychiatrists to remain involved to maximisecontinued coordinated rehabilitative efforts andreassessment. Specialists would also have a role inresearching and evaluating the various placementsavailable and this would address the currentconcerns of bodies such as the Mental Welfare

APT(1999), llo1. 5, p. 274 Smith & Hil/mllll

Commission about inappropriate detention andplacement of these patients.

Once suitable placement has been obtained thena process of multi-disciplinary assessment shouldbegin. This should include review by neuro­psychologists, occupational therapists, physio­therapists and appropriate psychiatric personnel.These patients may develop associated psychiatricproblems such a psychosis or depressive episodeswhich may need specific treatment (Lennane, 1986)

A method of classifying these patients that theauthors have found useful in clinical practice is theuse of the WeschlerAdult Intelligence Scale (Revised)(WAI>-R; Wechsler, 1981), for current intelligencequotient (IQ). The National Adult Reading Test(Nelson, 1982) will provide an approximation of thepatient's premorbid IQ and the Weschler MemoryScale (Revised) (WM>-R; Wechsler, 1987) indicatesthe types of memory deficit present and gives ameasure of memory quotient (MQ; Jacobsen &Lishman, 1987). The results of these tests are likelyto reveal a range of deficits which allows clas­sification of patients along the two axes of dementia(discrepancy between premorbid IQ and current IQ)and amnesia (discrepancy between IQ and MQ). Aswe have already stated, this has implications forprognosis in conjunction with information on modeof onset.

Tests of frontal lobe function and behaviouralmemory tests (Wilson et aI, 1985) may be useful asthey are likely to highlight more practical day-to­day problems and may guide rehabilitative effortsand eventual safe permanent placement.

Occupational therapy assessment may includehome-based assessments to ascertain whether areturn to the home situation with or without supportof relatives is feasible. Obviously the presenceof supportive carers is an important factor inrehabilitation.

Important in the assessment is whether patientsare felt to be at risk of relapse into drinking,particularly if placement in the original homecircumstances is being considered. It is a well­recognised clinical finding that these patients havea drastically reduced tolerance to even smallamounts of alcohol and will be at high risk of injurythrough severe intoxication or collapse. This mayresult in a further episode of Wernicke-Korsakoffsyndrome and impair their final recovery evenfurther (Blansjaar et aI, 1992).

Long-term assessment andmanagement

There is very little literature on this subject. It isknown that these patients once stable have a

normal life expectancy if abstinent from alcohol,and therefore long-term placement is an expensiveand important consideration. Clinical experienceand research suggest that after one year, any furtherrecovery is unlikely. However, it is known thatadaptation to a new environment can be facilitatedby appropriate rehabilitative efforts with emphasison improving conditioned learning.

Acute treatments

Intravenous or intramuscular thiamine supple­mentation is recommended to prevent progressionfrom Wernicke's encephalopathy to Korsakoffsyndrome (Cook & Thomson, 1997). This requiresa low threshold for making a presumptive diag­nosis in doctors working in accident and emergency,general medical and surgical wards, or anywards where patients are likely to be admitted ina confused state. Patients with head injury,hypothermia, reduced conscious level ortoxic confusional state should have Wernicke'sencephalopathy considered in their differentialdiagnosis and be given intravenous or intra­muscular thiamine.

The Korsakoff component of the Wernicke­Korsakoff syndrome associated with alcoholdependence, once established, is thought to bepoorly responsive to thiamine replacement treat­ment, but it is still important to treat the conditionaggressively at initial presentation with parenteralvitamins, given the very low incidence of complic­ations of this intervention. Obviously, removal fromthe drinking environment is also essential, as isadequate treatment of the alcohol-withdrawalsyndrome.

Intermediate and long-termtreatments

Specific drng treatmentfor Korsakoff syndrome

There have been various attempts to search forpharmacological agents to treat the amnesticsyndrome. Agents researched include fluvoxamine,methylphenidate and clonidine. A review of theseshows that there is no satisfactory evidence asyet for these agents to be used in routine clinicalpractice, and further research is required (seeKopelman, 1992; Ferrin, 1994 for reviews).

:\/coilo/l\orsllkof{slfl/dmll/L' /\/'1' (1999), "0/. .'i, p. 27.;

Drug treatment of associatedpsychiatric syndromes

These patients are at increased risk of variousassociated psychiatric syndromes (Lennane, 1986).In particular they may develop depression once theircognitive deficits are well-established. The depres­sion may be as a consequence of their organiccondition and, in particular, damage to the frontallobes in those with more global deficits than a pureamnestic syndrome. The depressive syndrome maybe worsened by a lack of stimulation or placementin an inappropriate environment, or it may be aresponse to partial insight into the extent of theirdeficits. These patients may develop psychoticepisodes which again may be worsened by sensorydeprivation.

In treating any associated depressive or psychoticsymptomatology it is advisable to avoid any drugswith anticholinergic properties. These may worsenthe patient's confusion and this may be related toevidence of cholinergic depletion in patients withKorsakoff syndrome, as may occur in those withAlzheimer's disease (Kopelman & Com, 1988).

Management of the alcoholproblem

Patients with established amnestic deficits may stillhave the urge to drink. Others may completely losethis and this will have obvious impact on suitabilityfor various placements. Those with a mild tomoderate Korsakoff syndrome are more likely todrink again. It is therefore essential that care is takento discourage the use of alcohol in these cases. Thereis evidence that repeated drinking will worsen thecognitive deficit over time.

Cognitive rehabilitation

There is a large literature on cognitive rehabilitationin general. There is less specific literature oncognitive rehabilitation in alcohol Korsakoffsyndrome. Readers interested in cognitive rehabilit­ation are referred to the Handbook of MemoryDisorders (Baddeley et aI, 1995). Cognitive rehabilit­ation encompasses specific techniques to encouragememory rehabilitation, design ofenvironments, useof memory prostheses and styles of nursing used topromote new learning.

Of prime importance is neuropsychologicalassessment to ascertain the specific cognitivedeficits in the patient and the degree of purity of theamnestic disorder. Psychologists may also have arole in doing a behavioural assessment to gain an

idea of the patient's functional problems secondaryto the memory deficits. These will obviously directrehabilitative efforts. Succesful memory rehabil­itation will depend on the patient's level ofmotivation, premorbid intellectual functioning andpreferred style of interaction.

This is of relevance in that patients with moreglobal alcohol dementia may have more apathy andreduced intellectual functioning, impairing theirresponse to specific memory rehabilitation. Thosewith a pure amnestic deficit may be more motivatedto make up the gap by use of memory prostheses,etc. Another factor impairing response to memoryrehabilitation may be unrecognised anxiety ordepressive disorders or social isolation andloneliness. This observation has led to developmentof memory groups by some workers. These can behelpful in reducing anxiety, social isolation orencouraging modelling of new learning techniques.

If the patient has to spend time at home or to havemore meaningful encounters with his family andavoid isolation, advice to families as to how toorganise information to improve recall may behelpful. This advice can be summarised as: a littleand often, checking understanding, encouraging thesufferer to link information and one piece ofinformation at a time. Carers may benefit fromcontact with a support group. For details of thesewe refer the reader to Wearing (1992).

Specific techniquesin memory rehabilitationin Korsakoff syndrome

Brooks & Baddeley (1976) demonstrated thatKorsakoff patients are capable of new learning,particularly if information is cued and of certaintypes. Patients can therefore learn new skills. Theyshowed that even densely amnestic patients canbenefit from cueing but have a limited capability offorming new procedural memories, that is, they candemonstrate the acquisition of new verbal and non­verbal skills but do not have the declarative memorycapabilities to code the learning of these skills asepisodes. Thus, a skill is learned without awarenessof the circumstances under which the learning tookplace, or in fact that it did take place. This hasimplications for teaching easily measured andSignificant information to patients, as well as forguiding the utilisation of memory prostheses, inorder to maximise patient autonomy.

There is some evidence from single uncontrolledcase reports that the use of visual imagery or verbalmediation is superior to rote learning in the

APT(1999), l'o!.5,p. 276 Smith & Hillllul/I

acquisition of verbal information. It also appearsthat the visual mode is superior to the verbal mode,but that there are difficulties in getting the patient togeneralise information learned. There is alsoevidence for certain styles of learning being superior.

A study of 16 patients with memory disorder and16 controls (Baddeley & Wilson, 1994) showed that'errorless' was superior to 'errorful' learning. Thepatients were able to recall more information over alonger period when they were not allowed to guess.An example of this would be a Korsakoff patientwho was lost in a ward and asked someone wherehis room is. In the errorful way of learning the patientwould be asked to guess where his room was andwould undoubtedly make a mistake. The errorlesslearning response would have been "I will showyou your room. This is your room". By eliminatingguessing, the patient avoids making early learningerrors which would then be repeated in a persever­ative fashion. This has obvious implications for thestyleofnursingorstyleofcaringby relativesofpatientswith amnestic disorders. Specific memory rehabilit­ation and use ofprosthetic memories is best promotedin a well-structured environment which reducesstress on memory and promotes new learning.

External memory aids

A large range of external memory aids is available(see Baddeley et ai, 1995). Memory aids can be basedon a very simple idea; for example, amnestic patientsare fitted with a bleeper which goes off to alert staffif they move too far away from the ward or hostel.Eventually, they would recognise themselves thatthe bleep means they should tum back.

Other simple memory aids include the making oflists or diaries through to the use of more complexelectronic memory aids such as personal organisersor computer programs. There are obvious problemsin teaching patients with a specific amnesticsyndrome to use these and, again, there is a clearrole for involvement ofa psychologist. A more recentdevelopment is a 'neuropage', which works like anordinary messenger pager that sends the wearer amessage saying, for example, "Take your medic­ation". These devices may be of relevance to peoplewith a milder amnestic deficit living at home orindependently. There is a need for further researchinto which types of memory aid and in what combin­ationsbest suit the rehabilitationofKorsakoffpatients.

Design of environment

For some patients with a very severe deficit, the mostappropriate way of maximising their indepen~encemay lie in the design of their environment. A carefully

thought out environment could provide cues toassist orientation and eventual new learning.Examples of these are improving patients' recog­nition of staff by changing their name badges tomake them easily readable and to reflect what nursesare actually called in the ward, rather than theirofficial title. Units should be on the ground floorwith large windows to aid patients' orientation forthe time of year or time of day. The use of arrows fordirection on the floor and colour-eoding of roomsand doors would also help orientation. The style ofnursing should reflect the research evidence infavour of errorless learning.

Legal issues

The use of the Mental Health Act may have to beconsidered with these patients in the early stages ofthe illness if they are clearly incapable of indepen­dent living, uncooperative with treatment and haveno adequate family support. At a later stageguardianship provision might need to be utilised inorder to move the patient on to the most suitableaccommodation. (Data in Scotland show that in theyear 1 April 1997 to 31 March 1998, out of 123guardianships granted, 20 were for patients withalcohol-related brain damage; A. Jacques, personalcommunication.) Additional legal measures maysometimes have to be considered in order to managepatients' financial affairs on their behalf. Restric­tions on personal finances can beeffective in limitingfurther misuse of alcohol in order to allow somepatients a degree of freedom to come and go whenwell-established in a particular placement.

Conclusions

In view of the above the authors contest that it is theduty of the psychiatrist to regularly review thesepatients to coordinate special assessment and toensure a placement that maximises the patients'independence within the limitations of their residualdisabilities (see Box 3). In other words:

"The eventual disposal of the patient to his family,nursing home or mental institution is undertaken onthe basis of the severity of the amnestic psychosis aswell as the existing family and social circumstances,but only after one is certain that no further improve­ment in memory function is pOSSible." (Victor et ai,1989).

Availability of some of the more specialisedrehabilitative techniques is limited in our current

· \/(0/10/ kll/·...II"-o(I ~lll/dl"lll/l(' \ I' / ( /999), "0/. ),1'.277

Box 3. Rehab 'litative principles

Regular review required in first year afterdiagno i

Eventual placement determined by carefulmulti-di ciplinary assessment

If patient not capable of independent livin~then provision of Mental Health Act andguardianship may have to be utilised

Social functioning can be improved with theuse of memory rehabilitation techniques

Design of environment to maximise indepen­dent living

Use whatever mean po ible to deter furtheruse of alcohol

health care system and there seems to be a case forthe development ofspecialist provision on a regionalbasis in areas where the condition is prevalent. Atleast two health boards in Scotland are currentlylooking at this possibility. There is a small literaturefrom Australia and The Netherlands suggesting thatsuch specialised provision can benefit these patientsin terms of social functioning.

References

Anonymous (1987) Memory testing: no thermometersavailable Lancet ii, 604-605.

Baddeley, A. D. & WIlson, B. A. (1994) When implicit learningfails: amnesia and the problem of error elimination.Neuropsychologia, 32, 53-68.

-, Wilson, B. A. & Watts, F, N. (eds) (1995) Handbook ofMemory Disorders. Chichester: John Wiley and Sons.

Blansjaar, B. A., Takens, H. & Zwinderman, A. H. (1992)The course of alcohol amnestic disorder: a three-yearfollow-up study of clinical signs and social disabilities.Acta Psychiatrica Scandinavica, 86, 240-246

Brooks, D. N. & Baddeley, A. D., (1976) What can amnesicpatients learn? Neuropsychologia, 14, 111-122.

Cook, C. C. H. & Thomson A. D. (1997) Review: B complexvitamins in the prophylaxis and treatment of Wernicke­Korsakoff syndrome. British Journal of Hospital Medicine,57, 461-465.

Cutting, J. (1978) The relationship between Korsakov'ssyndrome and 'alcoholic dementia'. British Journal ofPsychiatry, 132, 240-251.

Ferrin, J. M. (1994) Drug efficacy in the treatment of Wernickeand Korsakoff syndromes. Journal of Applied RehabilitationCounselling, 25, 32-36.

Ganzevles, P. G. J., De Geus, B. W. J. & Wester, A. J. (1994)Cognitive and behavioural aspects of Korsakoff'ssyndrome: The effect of special Korsakoff wards in ageneral psychiatric hospital. Tijdschrift voor Alcohol, Drugsen Andere Psychotrope Stoffen, 20, 20-31.

Jacobson, R. R. & Lishman, W. A. (1987) Selective memoryloss and global intellectual deficits in alcoholic Korsakoff'ssyndrome. Psychological Medicine, 17, 649-655.

Kopelman, M. D. (1992) The psychopharmacology of humanmemory disorders. In Clinical Management of MemoryProblems (2nd edn) (eds B. A. Wilson & N. Moffat), pp.189-215. London: Chapman & Hall.

- (1995) The Korsakoff syndrome. British Journal ofPsychiatry, 166, 154-173.

- & Com, T. H. (1988) Cholinergic 'blockade' as a modelof comparison of the memory deficits with those ofAlzheimer type dementia and the alcoholic Korsakoffsyndrome. Brain, 111, 1079-1110.

Kok, A. F. (1991) Developments in the care of Korsakoffpatients. Tijdschrift voor Alcohol. Drugs en AnderePsychotopic Stoffen, 17, 3-9.

Lennane, K. J. (1986) Management of moderate to severealcohol-related brain damage (Korsakoff's syndrome).Medical Journal of Australia, 145, 136-143.

Lishman, W. A. (1990) Alcohol and the brain. British Journalof Psychiatry, 156, 635-644.

Nelson, H. E. (1982) National Adult Reading Test (NARD forthe Assessment of Premorbid Intelligence in Patients withDementia: Test Manual. Wmdsor: NFER-Nelson.

Price, J. (1985) The Wernicke-Korsakoff syndrome inQueensland, Australia: antecedents and prevention.Alcohol and Alcoholism, 20, 233-242.

Ramayya, A. & Jauhar, P. (1997) Increasing incidence ofKorsakoff's psychosis in the East End of Glasgow. Alcoholand Alcoholism, 32, 281-285.

Victor, M., Adams, R. D. & Collins, G. H. (1971) The Wernicke­Korsakoff Syndrome and Related Neurological disorders Due toAlcoholism and Malnutrition (1st edn). Philadelphia, PA:F. A. Davis.

-, - & - (1989) The Wernicke-Korsakoff Syndromeand Related Neurological Disorders due to AlcoholismAnd Malnutrition (2nd edn). Philadelphia, PA:F. A. Davis.

Wearing, D. (1992) Self help groups. In Clinical Managementof Memory Problems (2nd edn) (eds B. A. Wilson & N.Moffat), pp. 271-304. London: Chapman & Hall.

Wechsler, D. (1981) WAIS-R Manual. New York: PsychologicalCorporation.

Wechsler, D. (1987) WMS-R Manual. New York: PsychologicalCorporation.

Wilson, B. A., Cockburn, J. & Baddeley, A. (1985) RivermeadBehavioural Memory Test. Bury St Edmunds: Thames ValleyTest Company.

Multiple choice questions

1. Recovery from alcohol Korsakoff syndrome(alcohol amnestic syndrome) is:a neverseenb unlikely if the condition is still present after a

yearc more likely with sudden onset casesd seen to some degree in the majoritye moreor lesscomplete in one-fifth to one-quarter

of cases.

2. Alcohol Korsakoff syndrome is:a always preceded by Wernicke's enceph­

alopathyb a progressiveneurodegenerative disorder with

decreased life expectancy, ~iven abstinencefrom alcohol

c characterised by a deficit in remote memorywith intact recent memory

d readily ameliorated with pharmacotherapye increasing in prevalence in some European

countries.

APT(999), 1101. S,p. 278 Smith & HilIllliIIl

3. Wernicke's encephalopathy:a is most commonly associated with alcohol

dependence in Western countriesb is due to deficiency of thiamine (vitamin B1)c should be treated initially with oral

thiamined is only present whan all three classical

features are seen (ophthalmoplegia, ataxia,confusion)

e can be present along with alcohol-withdrawaldelirium (delirium tremens).

4. The rehabilitation of individuals with alcoholKorsakoff syndrome is:a best served in general, non-specialised unitsb not possible as they have no capacity for new

learningc enhanced by the use of memory aidsd based on principles of 'errorful' learninge necessary to maximise social functioning.

5. The following may be useful in the managementof this patient group:a guardianshipb high doses of antipsychotic drugs with anti-

cholinergic propertiesc treatment of associated depressive illnessd continuity of psychiatric involvemente support services for carers.

CQan wers

1 2 3 4 5a F a F a T a F a Tb T b F b T b F b Fc F c F c F c T c Td T d F d F d F d Te T e T e T e T e T

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