The American Journal on Addictions, 21: 104–110, 2012 Copyright C  American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/j.1521-0391.2011.00199.x Evolution of Wernicke-Korsakoff Syndrome in Self-Neglecting Alcoholics: Preliminary Results of Relation with Wernicke-Delirium and Diabetes Mellitus Jan W. Wijnia, MD, 1 Ben J. M. van de Wetering, MD, PhD, 2 Elles Zwart, MSc, 1 K. Gerrit A. Nieuwenhuis, MD, 1 M. Anne Goossensen, MSc, PhD 3 1 Rijnmond Care Group, Nursing Home Slingedael, Center for Korsakoff and Psychogeriatry, Rotterdam, the Netherlands 2 Bouman GGZ, Mental Health Care, Addiction Care Psychiatry, Rotterdam, the Netherlands 3 Tilburg University, Tilburg School of Humanities, Tilburg, the Netherlands We present a descriptive, retrospective study of initial symptoms, comorbidity, and alcohol withdrawal in 73 alco- holic patients with subsequent Korsakoff syndrome. In 25/73 (35%) of the patients the classic triad of Wernicke’s en- cephalopathy with ocular symptoms, ataxia and confusion, was found. In at least 6/35 (17%) of the initial deliria (95% confidence interval: 10–25%) we observed no other underly- ing causes, thus excluding other somatic causes, medication, (recent) alcohol withdrawal, or intoxication. We suggest that these deliria may have been representing Wernicke’s encephalopathy. A high frequency (15%) of diabetics may reflect a contributing factor of diabetes mellitus in the evolution of the Wernicke-Korsakoff syndrome. (Am J Addict 2012;21:104–110) INTRODUCTION The Korsakoff syndrome is a chronic condition that may emerge when the acute phase of the Wernicke-Korsakoff syndrome resolves (Definitions, see Table 1). 1,2 Korsakoff syndrome is characterized by impairments of memory and executive functions, whereas the patient himself experiences no problems due to a reduced awareness of illness. Distur- bances of executive functioning constitute an important component of severe functional limitations that can be ob- served in Korsakoff patients, regarding initiative, planning, organizing, and regulating of behavior. 2–4 Timely and adequate treatment of thiamine deficits in patients with Wernicke-Korsakoff syndrome is critical to prevent the progress into the end-stage of the disease. 2 Received September 8, 2010; revised October 13, 2010; accepted February 10, 2011. Address correspondence to Dr. Wijnia, Rijnmond Care Group, Nursing Home Slingedael, Center for Korsakoff and Psychogeriatry, Krabbendijkestraat 495, 3084 LP Rotterdam, the Netherlands. E-mail: j.wijnia@zorggroeprijnmond.nl. When the Korsakoff syndrome is diagnosed without clinical features of preceding Wernicke’s encephalopathy (the triad of ocular symptoms, gait disorder, and confusion), the syn- drome may have developed insidiously. However, the pres- ence of Wernicke’s encephalopathy is often not recognized because of an atypical or incomplete presentation. 2,5,6 An early assessment of the risk of Wernicke-Korsakoff syn- drome is essential to prevent further damage from the neu- rological complications of thiamine deficiency. Nursing Home Slingedael offers a long-stay facility for patients with Korsakoff syndrome (90 patients). For triage purposes, a physician–elderly care and psychologist visited all referred patients prior to admission. During these vis- its we frequently saw patients who were wheelchair-bound, and suffering from delirium. In several cases we observed the delirium had been assigned to alcohol withdrawal, even though it was not made clear whether or not the patient had recently stopped or diminished drinking alcohol. Because of these “anecdotal” observations we wondered whether the delirium might have been a primary manifestation of encephalopathy prior to the development of Korsakoff syndrome, on the basis of an unrecognized Wernicke’s encephalopathy with incomplete presentation. Wernicke’s Syndrome The concept of a classic triad of signs and symptoms in Wernicke’s encephalopathy was based on the original de- scription by Carl Wernicke. The triad consists of an acute onset of a confusional state and impairment of conscious- ness, ataxia, and eye signs (nystagmus and ophthalmople- gia). However, as Wernicke himself described, and has been shown in subsequent studies, other important clinical signs and symptoms, such as nausea, vomiting, loss of appetite, and emotional changes, are often present before the later “classical” signs appear. 7,8 Furthermore, Wernicke wrote: “The question of whether the signs of delirium potatorum 104