"Wet Brain" - Wernicke-Korsakoff Syndrome

The term "Wet Brain" was once used in a derogatory manner many decades ago to describe those who abused alcohol and behaved in a bizarre manner. As a kid, these drinkers were often the source of entertainment for many, as they could be seen directing traffic until the police came along to remove them, spinning wildly exaggerated tales or staggering along the streets in the middle of the day, laughing and talking with their imaginary friend. They were often the "lovable" alcoholic who would hang around the bars waiting for patrons to buy them a drink and begin their "show" for the delight of those paying for this macabre form of entertainment.

Television programs often portrayed these drunken characters in a "cuddly" way, think of Otis Campbell on the Andy Griffith Show and Foster Brooks, the "hilariously funny" drunken comedian of the 1970s and 1980s. But in reality, there is nothing funny about alcohol abuse or the term "Wet Brain", which is actually a chronic and deadly condition known as Wernicke-Korsakoff syndrome. And some medical and addiction professionals are concerned that the COVID-19 lockdown could lead to increased cases of this condition, especially among older individuals.

Here in southeastern Massachusetts, a woman named Tracy had major concerns about her father, Bill. He is a widower, who is able to age in place in a small home he had purchased prior to the death of his wife from Alzheimer’s disease. Although they had explored assisted living, Tracy was happy they made the choice for him to remain home. “We decided on this with him prior to the pandemic and now that it has hit and decimated so many senior long-term care communities, we felt that we initially made the right choice.”

Bill is in his seventies and has some problems with his feet because of diabetes but was otherwise able to get around the house without much help. He was an active participant at the local senior center where he had many friends and often presented lectures about wildlife on the Southcoast of Connecticut. This was Bill’s passion since his retirement from teaching environmental science at a local community college.

Prior to his involvement in the senior center, Tracy had concerns about the amount of alcohol her father was consuming. “He never drank a lot, maybe wine at a meal, but after my mom was diagnosed with Alzheimer’s and he tried to take care of her at home, his drinking picked up,” Tracy said. “Then, when her condition progressed to a point where we needed skilled nursing care, his use of alcohol became out of control.”

“Following her death, it got even worse and we sent him to a counselor,” continued Tracy. It helped somewhat but the best thing that ever happened to him was getting involved in the senior center. There he had company and a sense of belonging that he lost when mom died.”

But with the pandemic came the lockdown. Medical offices closed, outdoor activities stopped, and worse of all for Bill, the senior centers ceased operations. And the senior center was more than just a place with friends for Bill. While there, he would receive a good meal, something he seldom took time to prepare at home and a set of professional and caring eyes kept tabs on his health and any concerning behaviors. Now with the center closed, Bill was closed in his house, by himself. In the beginning, he called his daughter twice a day, once at work and once at night before going to bed. But those calls stopped coming after a few weeks and his alcohol intake increased to abusive levels. "Once the senior center closed, he was really isolated, lonely, and drinking became his only activity,” stated Tracy.

"I couldn't be there every day, I had a job, kids being homeschooled and other responsibilities, so I initially hired a home healthcare agency to check in on him," she said. This did provide some relief for Tracy, but that feeling was short-lived. “He started to refuse their services and eventually refused to answer the door so they stopped coming. It was one of the home care providers who told us about all the empty bottles of wine and liquor that they found around the house and even in his bedroom. This was a huge red flag,” she said.

But Tracy had other concerns. “Dad’s cognition appeared to be failing as well. In one of his few calls to me, he didn’t remember things about mom, our family and even struggled with my name. He started talking about hearing animals in the house and about neighbors firing shotguns at the house. He would then launch into these long elaborate stories about things that on the face of them could not be true. At first, I thought he may have been drunk, but he wasn’t slurring his words. I began to think he was heading down the same road as my mother.”

Confabulation is a feature of WKS

The family tried to seek admission into a long-term care facility for him but the pandemic had shut down new admissions. Because Bill had trouble getting around, Tracy wondered how and where he was getting the alcohol. Then she found out from neighbors that the alcohol was being delivered by liquor stores that provided that service.

Tracy finally confronted her father on his drinking, which did not go well. "He seemed like a different person -- like he just gave up on life. Dad always had a spark about him that kept him going, but it was gone. He told me crazy stories about why he was drinking, stating that it prevented COVID and made his immune system stronger. I was able to get a doctor's appointment for him within a week and the news was not good. At first, they wanted to rule out Alzheimer's disease but now they are looking at alcoholic dementia. This is something I never heard of."

Unfortunately, Tracy's story is not out of the norm in this new COVID environment. According to Dr. Barry Freeman of the OptumCare Network in Arizona, “one out of five seniors are exhibiting signs of alcohol misuse.” And some treatment professionals feel that this number may be higher, much higher. Dr. Freeman points out that, “alcohol sales have risen nearly 50% during this pandemic.” Such numbers indicate that the lockdown may have some very serious unintended consequences that could be with our society for years, if not decades, to come.

The social distancing and stay at home orders of the pandemic certainly present a challenge for the senior population who are already vulnerable to the mental health effects of being isolated, making them not only disproportionately endangered by the coronavirus, but also by the effects of attempts to keep them safe by locking them down and cutting them off from the support systems that were in place.

So what are the dangers of alcohol on the brain? And can it cause dementia? The quick answer is yes, the longer answer is it's a very different type of dementia and one that is preventable.

Alcohol has a major effect on the brain cells in people of all ages but is especially devastating on the senior brain. Because long term alcohol drinkers often don’t take care of themselves nutritionally and physically, damage occurs to the brain as a result of poor nutrition and vitamin deficiencies. Long term alcohol use plus a lack of nutrition can lead to alcoholic dementia, which can mimic Alzheimer’s disease, especially in the way it affects memory and cognition. This type of dementia is Wernicke-Korsakoff’s syndrome (WKS), once referred to as “Wet Brain”.

This syndrome is actually two disorders that often go hand in hand but can occur individually. Wernicke’s encephalopathy is a disorder characterized by ophthalmoplegia (abnormal movements of the eye), ataxia (unsteady gait), and confusion. This can be followed by Korsakoff syndrome, which is responsible for psychotic features, among other symptoms.

WKS is not the direct result of alcohol but caused by damage to the cells as a result of a deficiency of thiamine (vitamin B1) due to poor nutritional habits and the leaching of nutrients from the body. Thiamine is an important nutrient for the brain as it produces energy from sugar. When levels of this vitamin fall to dangerously low levels, the brain fails to function properly. Although alcoholism is the most common cause of Korsakoffs, it can also be associated with AIDS, cancers that have metastasized, chronic infections, malnutrition, and some other conditions. It can also occur with a chronic illness where food is not absorbed properly or after bariatric surgeries.

If Wernicke’s is left untreated, it most often results in the development of Korsakoff syndrome, sometimes called Korsakoff psychosis, which causes significant impairments of memory and other cognitive functions. What stands out most about Korsakoff's psychosis is confabulation, where the individual makes up detailed, believable stories about certain experiences meant to cover gaps in memory.

Those suffering from this type of dementia also exhibit an inability to learn new things although other mental functioning may appear to be unaffected. At times, significant personality changes may also take place as well as the development of an apathetic stance towards life, where things they used to care very much about no longer have meaning. They also develop repetitive speaking patterns and behaviors which may be accompanied by a marked change in personality.

As an example, I once worked with a client diagnosed with this condition from the Boston area (a chronic drinker with AIDS), who would tell the same story in a session over and over with the same body language and expressions each time. He would not remember any of the questions that were asked of him. What made this quite remarkable was the fact that in spite of these confabulated stories, he was able to reason, was quite witty in sessions, and maintained the ability to play video games at a highly skilled level. This behavior of those with WKS is what can be confusing to loved ones who may initially fall into believing the fabricated stories when other areas of functioning appear normal, or in some cases, excelling in some activity requiring brainpower.

Physically, however, the body reveals the damage to the brain through the nervous system. This includes:

  • Abnormal eye movement

  • Reflexes that may be abnormal

  • An increased heart rate

  • Low blood pressure

  • A lower than normal body temperature

  • Muscle atrophy

  • Uncoordinated and problems with walking

So, can Wernicke-Korsakoff syndrome be treated? Yes, with some but's attached to that answer. If a person shows symptoms of Wernicke’s encephalopathy only, and if the intervention is early enough, treatment can be successful. When someone is admitted for alcohol detox and has been using for a significant period of time, symptoms of Wernicke’s is usually present. Part of the detox medication protocol includes thiamine and folic acid support to arrest or prevent further damage from Wernicke's encephalopathy.

However, if Korsakoff's psychosis is present, only partial reversal of the condition may be possible. Even more reason for concern is a warning from the National Institute on Alcohol Abuse and Alcoholism. Researchers at the NIAAA state that 80 to 90 percent of those who have Wernicke’s encephalopathy will develop Korsakoff’s at some point in their lives should the drinking behavior continue.

Diagnosing this condition can be even more tricky for clinicians, especially with older patients, often leading to a misdiagnosis. We go back to the case of Tracy who attributed her father’s behaviors to being drunk or the early development of Alzheimer's, when in fact it appears to be Wernicke-Korsakoff syndrome. Clinicians often struggle with this diagnosis since it can be masked by other conditions such as withdrawal, infection, or a head injury from a fall.

Earlier, we mentioned that treatment is possible in some cases. But what are the long term outcomes of individuals diagnosed with WKS? As previously highlighted, Wernicke encephalopathy is considered a serious medical condition that can cause death in two out of ten people. For those who develop Korsakoff’s with or without a previous episode of Wernicke encephalopathy, the outcomes vary as good information is lacking because longitudinal studies on this condition are in short supply.

Of the data that is available, it suggests that about 25 percent of those who develop Korsakoff will eventually recover, half show some improvement but don’t recover completely and the remaining 25 percent remain unchanged. In a nutshell, a full 75 percent of individuals who develop Korsakoff syndrome have their lives altered to some degree. On the positive side, there are a few studies that suggest those who do recover but abstain from alcohol use can have a normal life expectancy, albeit with some cognitive deficits.

So then the question becomes, what does a clinician do for those who show no improvement? In such cases, the treatment protocol moves away from attempting to treat Wernicke-Korsakoff to addressing the comorbid deficiencies and medical conditions while seeking long-term care placement for managing the behaviors of alcoholic dementia.

Now back to Tracy's father Bill and the tens of thousands of other seniors who are aging in place and living in isolation, many of whom are developing mental health issues and turning to alcohol in an attempt to alleviate the depression and pain of loneliness. Although we are focusing on the vaccine as an attempt to halt the spread of the virus, we have yet to adequately address the fact that the interventions imposed on society also carry negative health effects, something that needs to be addressed immediately and systemically. There exist tens, perhaps hundreds of thousands who are in the same position as Tracy, having a loved one using alcohol as a coping mechanism which will result in long-term consequences that we will be dealing with long after the pandemic has passed.

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