Wernicke-Korsakoff Syndrome - One of the Effects of Alcohol Abuse in Seniors
by Don Drake, Connelly Law Offices, Ltd. 7.1.24
"A March 2024 article in the New York Times highlighted the lack of awareness among older Americans about the risks associated with alcohol misuse and abuse," stated professional fiduciary and certified elder law Attorney RJ Connelly III. "While acknowledging its potential as a social lubricant when consumed responsibly, the article emphasized the fact that excessive alcohol consumption can turn it into an extremely toxic substance, something many older Americans are less likely to recognize as a danger to them."
The article also drew attention to the growing number of older individuals contributing to the rise in alcohol-related deaths, a trend that concerns healthcare providers and elder advocates. Even if the drinking behavior of older people remains unchanged, the increase in alcohol-related deaths is worrisome.
"The authors stated that drinking patterns have shifted among older individuals," said Attorney Connelly. "While the percentage of people over sixty-five reporting alcohol use in the past year (around 56 percent) and past month (about 43 percent) is lower compared to other adult groups, older drinkers are more likely to consume alcohol more frequently, on 20 or more days a month, than their younger counterparts."
Additionally, according to the newspaper story, a 2018 meta-analysis revealed a nearly 40 percent increase in binge drinking (defined as four or more drinks on a single occasion for women and five or more for men) among older Americans over the past 10 to 15 years. The pandemic has also had a major impact on this trend. According to the Centers for Disease Control (CDC), alcohol-related deaths, emergency room visits linked to alcohol, and alcohol sales per capita, all increased from 2019 to 2020 as COVID-19 emerged and restrictions were imposed.
Tracy's Story
Tracey, a resident of Maine, was deeply worried about her aging father, Bill, who lived in southeastern Massachusetts. He had been widowed and decided to continue living in the small house he had bought before his wife's passing, even as he battled Alzheimer's disease. Although moving to an assisted living facility was on the table, Tracey felt relieved that the family had chosen Bill to remain in his home. This decision proved especially beneficial during the pandemic, as it spared Bill from the potentially devastating impact of the virus on senior long-term care communities. However, as we will discuss later, this turned out to be a double-edged sword.
In his seventies, Bill grappled with diabetes and foot complications and continued to lead an autonomous life at his residence while staying engaged in activities at the nearby senior center. He dedicated his time there to delivering captivating wildlife presentations. This pursuit stemmed from his fervent interest in the subject after concluding his tenure as an environmental science instructor at a community college.
Before his involvement in the senior center, Tracey had concerns about her father's alcohol consumption. While he initially drank moderately, his alcohol use increased while caring for his wife. After her passing, it escalated even further until he sought counseling. The social worker at the center had connected Bill with a home health agency that recommended the senior center to him. There, Bill found companionship and a sense of belonging, which had been lost after his wife's death.
Then came the pandemic, and many facilities had to cease operations, including medical offices, outdoor activities, and senior centers. The center's closure was particularly impactful for Bill as it was more than just a social space. The center provided him with a healthy meal and monitored his health and well-being. The absence of this support led to increased isolation for Bill, compounded by the loss of his spouse.
Initially, he maintained regular contact with Tracy, who had a family of her own in Maine, but eventually, the calls from him became less frequent, and Bill's alcohol consumption escalated. Tracy sought help from the home healthcare agency to check on Bill, but he eventually refused their services and became increasingly withdrawn, even to the point of neglecting his health.
Due to his failing cognition, Bill began exhibiting concerning behaviors, such as not remembering vital details about the family, hearing non-existent sounds of animals in the house, and sharing elaborate but untrue stories. Tracy suspected his alcohol consumption might be a factor, especially after learning that liquor was being delivered to his home amid pandemic restrictions.
Confronting her father about his drinking led to a difficult conversation, during which he shared unfounded beliefs about alcohol protecting him from COVID-19 and boosting his immune system. Subsequent medical evaluation hinted at the possibility of alcoholic dementia, a condition Tracy had never heard of before.
Tracy spoke of her frequent travels from Maine to Massachusetts to visit her father, expressing her growing unease with each visit. After seeking help from a geriatric specialist, there was concern that her father might be suffering from Korsakoff Syndrome, also known as wet brain. This condition, often wrongly associated by many with homeless alcoholics, was unexpected for Tracy, given her father's background as a professional educator. The experience shed light on alcohol abuse in seniors, prompting Tracy to reevaluate her perspective on the issue.
"I have a huge sense of relief after finally finding the appropriate assistance for Dad," stated Tracy, "Regrettably, this involved the difficult decision to sell his house and seek out an assisted living program. The staff at the center are fully knowledgeable about Dad's diagnosis, which brings comfort to me, knowing that he is receiving the highest quality care possible. Nonetheless, I can't help but feel a sense of sadness for not identifying the problem earlier."
Post Pandemic Concerns
It's troubling to note that Tracy's experience is unfortunately not isolated in the aftermath of the COVID-19 pandemic. Dr. Barry Freeman, a respected figure at the OptumCare Network in Arizona, has highlighted that a significant proportion of seniors, approximately one in five, are displaying signs of alcohol misuse. Further, there are concerns among healthcare professionals that this number may be even higher. Dr. Freeman has drawn attention to the alarming fact that alcohol sales surged by almost 50% during the pandemic. These statistics point to the possibility of the lockdown having profound and enduring unintended consequences for our society, potentially for many years or even decades.
The pandemic brought about social distancing and stay-at-home orders, which posed a significant challenge for the senior population, particularly in terms of mental health. Attorney Connelly highlighted the "double-edged sword" faced by seniors, who were not only at higher risk from the virus but also greatly affected by the isolation and disconnection from their support systems. The effects of these measures were especially challenging for a population already vulnerable to the mental health impacts of isolation.
Wernicke-Korsakoff Syndrome - Wet Brain
The effects of alcohol on the brain cells are significant, particularly for individuals as they age. Long-term alcohol use can have devastating effects on the aging brain, especially when coupled with poor nutrition. Alcoholics often neglect their nutritional and physical needs, leading to damage from vitamin deficiencies. Prolonged alcohol use in conjunction with nutritional deficiencies can result in alcoholic dementia, which can present symptoms similar to Alzheimer’s disease, particularly in terms of memory and cognition. This type of dementia is known as Wernicke-Korsakoff’s syndrome (WKS) or 'wet brain.'
The exact prevalence of WKS across different populations remains unclear, with researchers suggesting that it may go undiagnosed in as many as 80 percent of cases. However, it is generally estimated that WKS affects approximately 1-2 percent of the overall population in the United States. This condition appears to impact slightly more males than females and is observed across a broad age range, from 30 to 70 years old. Notably, certain subgroups, such as the homeless, elderly individuals living in isolation, and psychiatric patients, have been found to have higher rates of WKS.
WKS encompasses two disorders that often occur together. Wernicke’s encephalopathy is characterized by abnormal eye movements (ophthalmoplegia), an unsteady gait (ataxia), and confusion. This may be followed by Korsakoff syndrome, which is responsible for accompanying psychotic features and other neurological abnormalities.
WKS is not directly caused by alcohol but rather results from damage to brain cells due to a deficiency of thiamine (vitamin B1) due to poor nutrition and the depletion of nutrients from the body. Thiamine is an essential nutrient for the brain, supporting energy production from sugar. The brain's functioning is impaired when thiamine levels drop to critically low levels. While alcoholism is the primary cause of Korsakoff's syndrome, it can also be associated with AIDS, metastasized cancers, chronic infections, malnutrition, and other conditions. It can even occur due to a chronic illness that hinders proper nutrient absorption, such as following bariatric surgeries.
If Wernicke’s encephalopathy remains untreated, it frequently leads to the development of Korsakoff syndrome, also called Korsakoff psychosis, which causes significant impairments in memory and other cognitive functions. One prominent feature of Korsakoff's psychosis is confabulation, wherein individuals create detailed and believable stories about certain experiences to fill gaps in memory.
Individuals affected by this form of dementia may struggle to learn new information, even as other mental functions might appear unaffected. They may also undergo significant personality changes and develop an apathetic attitude toward life, losing interest in things that were once significant to them. Additionally, they may display repetitive speech patterns and behaviors.
Physically, signs of brain damage are evident through the nervous system, such as abnormal eye movements, unusual reflexes, an elevated heart rate, low blood pressure, a lower-than-normal body temperature, muscle atrophy, and difficulties with coordination and walking.
Treatment of WKS
Can Wernicke-Korsakoff syndrome be treated? Yes, but certain conditions come with that answer. Treatments can be effective if a person displays symptoms of Wernicke’s encephalopathy alone and receives early intervention. When an individual is admitted for alcohol detox after prolonged drinking, symptoms of Wernicke’s encephalopathy are often present. As part of the detox medication protocol, thiamine and folic acid support are administered to halt or prevent further damage from Wernicke's encephalopathy.
However, if Korsakoff's psychosis is also present, only partial reversal of the condition may be achievable. Another cause for concern is a warning from the National Institute on Alcohol Abuse and Alcoholism. According to researchers at the NIAAA, 80 to 90 percent of individuals with Wernicke’s encephalopathy will develop Korsakoff’s at some point in their lives if their alcohol consumption continues.
Diagnosing WKS
Diagnosing Wernicke-Korsakoff syndrome (WKS) can be particularly challenging for clinicians, especially when dealing with older patients, often resulting in misdiagnosis. Take the case of Tracy, who initially attributed her father’s behaviors to being drunk or an early development of Alzheimer's, when, in fact, it turned out to be Wernicke-Korsakoff syndrome. Clinicians often struggle with this diagnosis because it can be overshadowed by other conditions such as withdrawal, infection, or even head injuries from falls during drinking episodes.
Treatment is sometimes possible, but what are the long-term outcomes for individuals diagnosed with WKS? Wernicke encephalopathy is a serious condition that can lead to death in two out of ten people. The outcomes vary for those who develop Korsakoff’s, with or without a previous episode of Wernicke encephalopathy. Longitudinal studies on this condition are limited, but available data suggests around 25 percent of those who develop Korsakoff will eventually recover, half will show some improvement but won’t fully recover, and the remaining 25 percent will remain unchanged. This means that 75 percent of individuals who develop Korsakoff syndrome will have their lives altered to some degree. On a positive note, a few studies suggest that those who recover and abstain from alcohol use can have a normal life expectancy, albeit with some cognitive deficits.
So, what does a clinician do for those who show no improvement? In such cases, the treatment protocol transitions from attempting to treat Wernicke-Korsakoff to addressing the comorbid deficiencies and medical conditions while seeking long-term care placement for managing the behaviors associated with alcoholic dementia.
A Final Word
Attorney Connelly emphasized the enduring significance of the measures put in place during the COVID-19 pandemic, specifically concerning the well-being of elderly individuals. He underscored the widespread use of alcohol as a means of coping among our seniors during that time, underscoring the necessity for continuous initiatives to tackle this problem. Educating families about the hazards linked to alcohol misuse and abuse in the elderly is vital, as these issues are anticipated to be present for years and even decades.
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