Neuro-Cognitive Rehabilitation/Retraining in Alcoholic Korsakoff Syndrome: A Case Report

INTRODUCTION

Korsakoff syndrome is a chronic memory  disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome. Alcoholic Korsakoff patients have their most marked deficits in memory, but may exhibit problems in further cognitive and behavioral domains, particularly in so-called frontal lobe functions and on the emotional level (Brand et al., 2003). Problem solving and visuo-perceptual deficits seem to develop slowly during decades of alcoholism, the amnesic symptoms associated with Korsakoff’s Syndrome may appear acutely when severe malnutrition and alcoholism are combined. Korsakoff’s syndrome may be more accurately characterized as a “basal forebrain” than as a “diencephalic” amnesia. (Butters, 1985). Next to amnesia, executive deficits are a prominent characteristic of cognitive impairment in Korsakoff patients (Van Oort & Kessels, 2009). The evidence base for rehabilitating alcohol-related brain damage is still in its infancy. However, the available evidence suggested benefits of a number of memory rehabilitation strategies (Svanberg & Evans, 2013). Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem-solving, and executive functions. In comparing patients with Korsakoff’s syndrome and healthy controls, it was found that giving more time, greater explanation and encouraging patients with Korsakoff’s syndrome to explain increased their performance in making associations between learned pairs of words (Van Damme & d’Ydewalle, 2008). Svanberg and Evans’s review emphasizes the importance in providing structured rules to facilitate problem-solving difficulties encountered in patients with Korsakoff’s syndrome. It is suggested that the effect of cognitive rehabilitation can be enhanced by tailoring the intervention to the specific needs of each patient (Fals-Stewart & Lucente, 1994). 

CASE REPORT

A 58 Years old married male educated up to M.A. with middle Socio-economic status living in nuclear family with his wife and two children was presented to psychiatry OPD with a history of alcohol abuse from last sixteen years along with forgetfulness and retardation in psychomotor activity from last two years. Patient had started taking alcohol occasionally from 1997 in the company of his friends. He started taking it daily after a few days because of its euphoric effects. Patient spoiled most of his money in alcohol. Whenever his wife told him to quit alcohol, he got angry and become violent. Sometimes he would become violent and beat his wife and children on trivial issues. His family members told him to leave alcohol and took treatment many times but he never agreed. After 3-4 years later he started remaining drunk (Intoxicated State) for the whole day. Due to his financial constraints patient was unable to take alcohol from last 2 years before presenting in the OPD. His wife noticed changes in his behavior. Wife reported that he used to forget things and recent events easily. Patient’s wife told him to buy something from market, but he would usually forget although, his memory for past events was intact. He did not listen to other’s conversation and repeatedly ask what others had spoken. He was not able to concentrate on his work. So, he left his job. Patient had never taken any treatment to leave alcohol. On Mental Status examination he was not much cooperative. His speech was not clear. He got irritated when told him to remember a thing and reply after some time. On assessment of cognitive functions, he did not cooperate much. Disturbances in recent memory were found. Insight was partial and judgment intact.

ASSESSMENT OF NEURO-COGNITIVE FUNCTIONS

With the consent of the patient and family a detailed Assessment of cognitive skills was carried out at pre-intervention using NIMHANS neuropsychological Battery (Shobni Rao, 2004). On the basis of overall test findings pertaining to different lobes clinical observation and history it was found that frontal lobe functions, category fluency and planning were intact but mental speed, attention, verbal fluency, working memory and set shifting were found to be significantly impaired suggesting specific involvement of the dorsolateral prefrontal cortex or may be the connections to other lobes. On further analysis of memory function, it was found that patient had problem in encoding the information related to verbal and nonverbal aspects since the mental speed and attentional processes were significantly impaired. He did not have much problem in retrieval from stored information whatever he could learn in different trials. Pre intervention assessment of cognitive skills also suggested presence of deficits in basic functions such as sustained attention, slow mental processing speed which are an essential component of encoding the information through prefrontal areas. Therefore, involvement structures related to memory in temporal lobe was not significant. Furthermore, his comprehension ability was also found to be inadequate which could have affected the overall assessment process. For the assessment of parietal lobe dysfunction agnosias, apraxias and focal signs were clinically tested which were found to be grossly intact suggestive of parietal lobe sparing. Since problem in attention, mental speed was an important component in the assessment of visuospatial ability, therefore these function’s adequacy could not be commented. Considering his history of chronic alcohol intake, inadequate job performance, inadequate decision-making ability, slowness in the activity of daily living and the above neurological dysfunction and adequate function profile was clinically related to his socio occupational and psychological functioning. Overall test findings, clinical observation and history was suggestive of specific involvement of dorsolateral pre frontal cortex and its connection to anterio-superior region of the temporal lobe. 

MANAGEMENT AND OUTCOME

Based on the obtained profile (pre-assessment) a Neuro-Cognitive Rehabilitation plan was developed.

Neuro-Cognitive Rehabilitation

Rationale for Neuro-Cognitive Rehabilitation: 

Cognitive rehabilitation is perceived as a proven treatment in many clinical conditions. It involves therapies that are designed to improve damaged intellectual, perceptual, psychomotor, and behavioral skills, and to increase levels of self-management and independence following damage to the central nervous system. Cognitive rehabilitation helps to improve damaged cognitive functions such as attention, memory and learning, affect and expression, problem-solving, and executive function. The desired outcome of cognitive rehabilitation is an improved quality of life or an improved ability to function in home and community life.

Goal of Cognitive Rehabilitation: The goal of cognitive rehabilitation was to enhance the patient’s capacity to process and interpret information and to improve his ability to function in all aspects of family and community life. 

Process of Cognitive Rehabilitation: Method of restoration and repetitive use of tasks were done for improvement in different cognitive functions. During initial sessions focus was to improve attention and concentration

ATTENTION BUILDING TASKS

Activities for Focused Attention: Bead making, grain sorting tasks were used to improve focused attention and information processing. Bead making activity had 3 levels: large beads, small beads and very small beads. Each of the level was done for approximately 8-10 sessions. For next 20 session’s grain sorting was also done. It was also done on two levels: mixed two grains and three types of grain from large to small size.

Outcome Focused Attention: In the initial few sessions patient took a long time to complete the activity but after a few days he was able to do the task effectively with less time. In the initial sessions patient took approximately 2 minutes to complete but after a few days time reduced to 1 minute to few seconds only. 

Attention on grain sorting activity was also improved. In the earlier sessions, patient was having confusion in sorting the grains. But in later sessions, he was able to perform the task effectively and time duration was also decreased.

Activities for Sustained Attention: Single and double letter cancellation tasks were used. Errors were also noted down in all the sessions. 

Outcome of Sustained Attention: Errors and time taken were significantly reduced to almost 60%.

VERBAL MEMORY

Activities for Verbal Memory: Patient was made to recall five words immediately for 5 trials. After few sessions, delayed recall was practiced that is after 1, 5, 10 minutes.  

Outcome of Verbal Memory: Patient made few errors in immediate recall but made more errors in delayed recall. After few sessions, patient was able to perform well on 1,5minute recall but not on 10 minutes. 

Activities for Visual Memory: Five different items were shown and patient was made to recall them immediately and after 2 minutes. 

Outcome of Visual Memory: patient performed well on this task.

VERBAL FLUENCY

This activity was done to increase the ability to generate new words and to increase mental flexibility.

Activity for Phonemic Fluency: The controlled word association test (COWA) which is a sub test of NIMHANS battery was used for phonemic fluency. The subject had to generate words based on the phonemic similarity of the words. He had to generate words beginning with different letters like Ma,Pa,Ka,Ba,Ra in one and two minutes. Proper nouns and names of numbers should not be used.

Overall Outcome of Cognitive Rehabilitation: In the initial sessions, patient was able to generate 10 words which improved to 15-20 words. His attentiveness was improved to 80%. His performance on conversational skills improved to 70-80%. Overall improvement in attention concentration rated by the trainer was 70-80% and 40% improvement in immediate recall and retention. The improvement was generalized to other areas also. His attention in social communication was also improved. He was able to learn the social skills effectively and showed improvement in listening, expressive and assertiveness skills. Listening, expressive and assertive skills were improved significantly.

DISCUSSION

The aim of the present study was to develop a tailor-made Neuro-Cognitive Rehabilitation for Alcoholic Korsakoff Syndrome patient and review its effectiveness. Initially the focus was to improve attention and concentration. In the present case study, the cognitive retraining of Attention tasks, Memory and Verbal Fluency was done with an expectation of improvement in in these areas with the help of family members as Evidence also exists in the literature in support (Monteiro et al., 2011). Chronic use of different substances is associated with neural dysfunctions and related cognitive deficits. (Ekhtiari et al., 2021). In the index case patient also had deficits sustained attention, slow mental processing speed and memory functions which were developed after his chronic alcoholism.  After cognitive rehabilitation maximum gains were observed in memory and expressive language. Morgan et al  used memory cuing, both through staff and electronic diary prompting, to successfully enhance attendance at meetings and therapeutic programmes (Morgan et al., 1990).  Training visual working memory capacity could possibly optimize other cognitive difficulties (Oudman et al., 2020).

CONCLUSION

Cognitive retraining proved to be a very effective method in this case and seen as a very useful approach in many clinical conditions, like head injury, stroke. Large amount of data is available to prove this statement. A drastic change could be noticed in the patient, which could also be observed by his family members. 

RECOMMENDATIONS

1. Cognitive Rehabilitation should be tailored as per patient’s needs after a detailed neuro-cognitive assessment.

2. Role of family is important when it comes to practice of tasks of cognitive rehabilitation.

REFERENCES

Brand, M., Fujiwara, E., Kalbe, E., Steingass, H. P., Kessler, J., & Markowitsch, H. J. (2003). Cognitive estimation and affective judgments in alcoholic Korsakoff patients. Journal of Clinical and Experimental Neuropsychology, 25(3), 324-34

Butters, N. (1985). Alcoholic Korsakoff’s syndrome: Some unresolved issues concerning etiology, neuropathology, and cognitive deficits. Journal of Clinical Neuropsychology, 7(2), 181-210 

Ekhtiari, H., Zare-Bidoky, M., & Verdejo-Garcia, A. (2021). Neurocognitive Disorders in Substance Use Disorders. In Textbook of Addiction Treatment (pp. 1159–1176). Springer International Publishing. 

Fals-Stewart, W., & Lucente, S. (1994). The effect of cognitive rehabilitation on the neuropsychological status of patients in drug abuse treatment who display neurocognitive impairment. Rehabilitation Psychology, 39(2), 75–94.

Monteiro, M. de F. A., Bolognani, S. A. P., Rivero, T. S., & Bueno, O. F. A. (2011). Neuropsychological intervention in a case of Korsakoff’s amnesia. Brain Impairment, 231-238. 

Morgan, J., McSharry, K., & Sireling, L. (1990). Comparison of a system of staff prompting with a programmable electronic diary in a patient with korsakoff’s syndrome. International Journal of Social Psychiatry, 36(3):225-229

Oudman, E., Schut, M. J., Ten Brink, A. F., Postma, A., & Van der Stigchel, S. (2020). Visual working memory capacity in Korsakoff’s amnesia. Journal of Clinical and Experimental Neuropsychology, 42(4), 363–370. 

Svanberg, J., & Evans, J. J. (2013). Neuropsychological rehabilitation in alcohol-related brain damage: A systematic review. Alcohol and Alcoholism, 48(6),704-11 

Van Damme, I., & d’Ydewalle, G. (2008). Elaborative processing in the Korsakoff syndrome: Context versus habit. Brain and Cognition, 67(2), 212–224

Van Oort, R., & Kessels, R. P. C. (2009). Executive dysfunction in Korsakoff’s syndrome: Time to revise the DSM criteria for alcohol-induced persisting amnestic disorder? International Journal of Psychiatry in Clinical Practice, 13(1),78-81.

Conflict of interest: None
Role of funding source: None