C International Psychogeriatric Association 2013 International Psychogeriatrics (2014), 26:1, 115–121 doi:10.1017/S1041610213001543
Patients with Korsakoff syndrome in nursing homes: characteristics, comorbidity, and use of psychotropic drugs ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Ineke J. Gerridzen1 and M. Anne Goossensen2 1 2
Atlant Care Group, Nursing Home Markenhof, Beekbergen, the Netherlands University of Humanistic Studies, Utrecht, the Netherlands
ABSTRACT
Background: Very limited literature exists on the care and course of patients with Korsakoff syndrome (KS) living in long-term care facilities (LTCFs). Even less literature can be found on the pharmacological treatment of behavioral symptoms of KS. The purpose of the present study was to describe baseline characteristics, comorbidity, and the use of psychotropic drugs in institutionalized patients with KS. Methods: In this cross-sectional descriptive study, 556 patients were included living in ten specialized care units in Dutch nursing homes. Data were collected by means of a retrospective chart review. Results: The majority of patients were men (75%) and single (78%) with a mean age on admission of 56.7 years (SD 8.9, range 29.8–85.3). Mean length of stay was 6.0 years (SD 5.4, range 0.2–33.3). Sixty-eight percent of patients suffered from at least one somatic disease and 66% from at least one extra psychiatric disorder. One or more psychotropic drugs were prescribed to 71% of patients with a great variation in prescription patterns between the different nursing homes. Conclusion: Patients with KS depending on long-term care usually have comorbidity in more than one domain (somatic and psychiatric). The indications for prescribing psychotropic drugs are in many cases unclear and it seems probable that they are often given to manage challenging behavior. Longitudinal studies on the evidence for this prescription behavior and possible alternatives are recommended. Key words: Korsakoff syndrome, alcohol-related dementia, long-term care, nursing homes, comorbidity, psychotropic drugs, behavioral symptoms
Introduction Korsakoff syndrome (KS) is a chronic neuropsychiatric condition, characterized by a severe memory disorder resulting from acute Wernicke’s encephalopathy mostly secondary to chronic alcohol abuse and concomitant thiamine deficiency. In the Netherlands, there are specialized long-term care facilities (LTCFs) for patients with KS. Many institutionalized patients with KS show challenging behavioral symptoms like lack of awareness of the illness, aggression, sexual disinhibition, and apathy. These symptoms may lead to prescription of psychotropic drugs and put a heavy strain on caregivers. From studies of nursing home patients with dementia, it is known that a large percentage of patients have at least one behavioral symptom Correspondence should be addressed to: Ineke J. Gerridzen, MD, Elderly Care Physician, Atlant Care Group, Nursing Home Markenhof, Kuiltjesweg 1, 7361 TC Beekbergen, the Netherlands. Phone: +31-55-5067200; +31-651263852; Fax: +31-55-5067201. Email: [email protected]. Received 19 Dec 2012; revision requested 20 Jan 2013; revised version received 31 Jul 2013; accepted 7 Aug 2013. First published online 9 September 2013.
and despite modest effects and the risk of adverse effects, psychotropic drugs such as benzodiazepines, antipsychotics, and antidepressants are commonly prescribed in the LTCF setting (Pitkala et al., 2004; Gobert and D’Hoore, 2005; Sink et al., 2005; Ballard and Howard, 2006; Lovheim et al., 2006; Schneider et al., 2006; Selbaek et al., 2007; Eggermont et al., 2009; Kleijer et al., 2009; Nijk et al., 2009; Wetzels et al., 2011). Prevalence rates for behavioral symptoms and the use of psychotropic drugs in patients with KS residing in LTCFs might be even higher. However, institutionalized patients with KS have not been studied separately and extensively before and limited literature is available on the long-term care and course of this group of patients. Prevalence studies are out-of-date or scarce (Blansjaar et al., 1987; Harper et al., 1989; Kopelman, 1995; Schepers et al., 2000; Kopelman et al., 2009; Draper et al., 2011; Wijnia et al., 2012). Once institutionalized, the care needs of patients with KS are often not recognized adequately (Schepers et al., 2000). Often clear
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diagnostic criteria for KS are missing (Oslin et al., 1998; Galvin et al., 2010) and current diagnostic criteria for KS are mainly on clinical judgment. There is accumulating evidence that patients with KS have impairments in executive functioning. The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) (American Psychiatric Association, 1994) criteria for “alcohol-induced persisting amnestic disorder” do not take this into account (Oort and Kessels, 2009). The term alcoholic dementia is controversial and has generally been superseded by the concept of alcohol-related dementia, encompassing a broader definition of alcohol-related cognitive deficits (Victor, 1994; Oslin et al., 1998; Gupta and Warner, 2008). Some authors consider cases of alcohol-related dementia to be, in fact, KS (Victor, 1994; Oslin et al., 1998; Kopelman et al., 2009). The aim of this study was therefore: (a) to describe baseline characteristics and comorbidity and (b) to describe the use of psychotropic drugs in patients with KS residing in special care units in Dutch LTCFs.
Methods Participants In this cross-sectional descriptive study, 556 residents of ten special Korsakoff units in Dutch LTCFs were included. These facilities cooperate in a centre, which strives for developing knowledge, practice, and skills in the widest possible sense for patients with KS. This centre is called “the Dutch Korsakoff Knowledge Centre.” Participants were included when they had the following diagnoses reported in the medical chart: KS, Wernicke-Korsakoff encephalopathy, alcoholinduced persisting amnestic disorder, persistent cognitive impairment due to alcohol, alcoholinduced persisting dementia, and/or alcoholic dementia. Data collection All patient data were collected by one researcher (the first author) by means of a retrospective chart review. The investigation was performed on an arbitrary reference date during the period August 2011 to May 2012. The following data were retrieved from patients’ electronic administration files and medical charts: demographic data, patients’ representatives (legal and/or informal caregivers), admission dates, somatic and psychiatric comorbidity, and use of psychotropic drugs. The date of last admission was used in case there were multiple records. Somatic comorbid conditions were classified as follows:
COPD, cardiovascular diseases, hypertension, diabetes mellitus, cerebrovascular accident, epilepsy, and malignancy. Psychiatric comorbid conditions were classified as: mental retardation, psychotic disorders, mood disorders, anxiety disorders, personality disorders, other substance use disorders, and others. Suicide attempts, though not a DSMdisorder, were also registered. The prescribed psychotropic drugs were derived from patients’ prescription records and classified into three major categories: antipsychotics, antidepressants, and benzodiazepines. “As needed” (PRN) medication was not included. The use of these psychotropic drugs was compared to the prevalence of psychiatric diagnoses, which were mentioned in the medical charts. Analysis All demographic data, patients’ representatives (legal and/or informal caregivers), admission dates, somatic and psychiatric comorbid conditions, and prescriptions of psychotropic drugs were entered into a spreadsheet, using Microsoft Office Excel, version 14.1.0, 2010. The resulting database enabled descriptive analyses such as grouping and summarizing all data, calculating the mean and standard deviation (SD) and creating frequency tables and figures. Ethical and legal considerations Information about this study was provided to the patients or their representatives, the local client advisory boards and the management of the participating nursing homes. Although requesting patients’ informed consent was not necessary because of the retrospective nature of this study using only data from patients’ charts and processing these data anonymously into a large study group, patients or their representatives could refuse to participate. The local Research Ethics Committee at the Medical Centre of Leeuwarden approved the study.
Results In this study, no patients or representatives refused to participate. Baseline data was available for 556 patients with KS and are presented in Table 1. Mean age on admission was 56.7 years (SD 8.9, range 29.8–85.3) and most patients were men (75%). Mean age at reference date was 62.8 years (SD 8.4, range 40.8–85.8). The mean length of stay was 6.0 years (SD 5.4, range 0.2–33.3). Fifty-three percent of patients were divorced, 25% single, 9% still married, and 10% widowed. Nearly one-fifth of patients (19%) had a trustee or mentor as a legal representative. In only 3% of cases,
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Table 1. Patients’ characteristics (n = 556) CHARACTERISTIC
N (%
OF TOTAL POPULATION)
.......................................................................................................................................................................................................................
Gender male Mean age at reference date 80 years Mean length of stay at reference date 20 years Any somatic condition COPD Cardiovascular disease Hypertension Diabetes mellitus Cerebrovascular accident Epilepsy Malignancy Any psychiatric condition Mood disorders Psychotic disorders Personality disorders Suicide attempts Other substance use disorders Mental retardation Anxiety disorders Other psychiatric disorders
the trustee or mentor was a family member. 75% of patients had a relative as informal representative (partner 9%, child 26%, brother or sister 34%, nephew or cousin 2%, parent 4%, 6% a non-family member, and 2% no-one). Sixty-eight percent of patients suffered from at least one somatic comorbid condition. COPD (30%) and cardiovascular disease (25%) were common. Other comorbid conditions were: hypertension (16%), diabetes mellitus (16%), cerebrovascular accident (14%), epilepsy (14%), and malignancy (13%). Twenty-two patients (4%) had a malignancy of the oropharynx; 4 patients (1%) suffered from a lung carcinoma. More than half of the patients had at least one psychiatric comorbid condition (59%) as shown in Table 1. About twice as many had a mood disorder (32%) compared to the number with a psychotic disorder (18%). Personality disorders were mentioned in the medical charts in 15%. Suicide attempts were mentioned in 9%, mental retardation in 7%, and anxiety disorders in 6%. In addition to the alcohol abuse, there were also other substance use disorders (7%). Other comorbid
415 (74.6) 62.8 (SD 8.4) (range 40.8–85.8) 30 (5.4) 311 (55.9) 202 (36.3) 13 (2.3) 6,0 (SD 5.4) (range 0.2–33.3) 76 (13.7) 223 (40.1) 159 (28.6) 81 (14.6) 17 (3.1) 376 (67.6) 167 (30.0) 137 (24.6) 90 (16.2) 90 (16.2) 79 (14.2) 79 (14.2) 72 (13.0) 329 (59.2) 177 (31.8) 100 (18.0) 84 (15.1) 52 (9.4) 39 (7.0) 37 (6.7) 35 (6.3) 12 (2.2)
Table 2. Prevalence of psychotropic drug use (n = 556) TYPE OF MEDICATION
N (%)
........................................................................................................................................................
One or more psychotropic drug Type of psychotropic drug Antipsychotic Antidepressant Benzodiazepine Combination of drugs Antipsychotic + antidepressant Antipsychotic + antidepressant + benzodiazepine Antipsychotic + benzodiazepine Antidepressant + benzodiazepine
393 (70.7) 269 (48.4) 224 (40.3) 191 (34.4) 74 (13.3) 59 (10.6) 62 (11.2) 37 (6.7)
Note: All values in brackets are presented as a percentage of the total group.
conditions, which were found, were somatoform and eating disorders (2%). Table 2 shows the percentages of patients of the total group who were prescribed psychotropic drugs at reference date. Altogether nearly 71% of the
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Figure 1. Psychotropic drug use in percentages per nursing home.
residents were prescribed one or more psychotropic drugs. Twenty-nine percent used one type, 31% two types, and 11% at least three types of psychotropic drugs. Forty-eight percent of all patients used an antipsychotic drug, 40% an antidepressant drug, and 34% a benzodiazepine. Forty-two percent of all patients used a combination of two or three psychotropic drugs. In particular, the combination of an antipsychotic drug and an antidepressant drug was the most frequently prescribed combination (13%). Figure 1 shows the different prescription patterns of psychotropic drugs in the 10 LTCFs. The use of antipsychotics, antidepressants, and benzodiazepines varies per nursing home. Particularly in nursing homes VIII en X, nearly 70% of patients with KS used an antipsychotic drug. This contrasts with nursing home VII where only 17% of patients used an antipsychotic drug. The percentage of antidepressant users ranges between 25% (nursing home VII) and 71% (nursing home X). The percentage of benzodiazepine users ranges from 8% (nursing home VII) to 48% (nursing home III). In nursing home X, the percentages both of antipsychotic users (67%), antidepressant users (71%), and benzodiazepine users (46%) are high in contrast to nursing home VII (17%, 25%, and 8%, respectively). In general, antipsychotics were most frequently prescribed. Of the prescribed psychotropic drugs benzodiazepines were the least prescribed. Figure 2 combines percentages of patients with at least one psychiatric condition with the percentages
of at least one prescribed psychotropic drug per nursing home. The percentage of at least one prescribed psychotropic drug ranges from 33% (nursing home XII) to 83% (nursing home X). In contrast the percentage of patients with at least one psychotic disorder ranges from 47% (nursing home V) to 74% (nursing home III). The differences between the percentage of at least one prescribed psychotropic drug and the percentage of patients with at least one psychotic disorder strongly varies between nursing homes. In Table 3 the difference between percentages of users of a psychotropic drug and percentages of patients with a psychotic and a mood disorder are further specified per nursing home. Again, large differences are found between users of a psychotropic drug and patients with a psychiatric condition. For psychotic disorders, the differences between users of an antipsychotic drug and the disorder vary from 15% (nursing home II) to 46% (nursing home X). This suggests that patients with KS in nursing home X were prescribed antipsychotic drugs with an indication other than psychotic disorder more often than in nursing home II. For mood disorders, the differences are less striking. In four nursing homes, percentages of users of an antidepressant are even lower than percentages of patients with a mood disorder. Despite mood disorders occurring more often than psychotic disorders overall, antipsychotic drugs were prescribed more often than antidepressant drugs.
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Figure 2. Patients with ࣙ1 psychiatric condition and psychotropic drug use in percentages per nursing home.
Table 3. Use of a psychotropic drug in relation to indication in percentages per nursing home (n = 556)
NURSING HOME
PSYCHOTIC DISORDER
ANTIPSYCHOTIC DRUG
INDICATION OTHER THAN PSYCHOTIC DISORDER
MOOD DISORDER
INDICATION OTHER THAN ANTIDEPRESSANT MOOD DISORDER DRUG
............................................................................................................................................................................................................................................................................................................................
I II III IV V VI VII VIII IX X
19 17 28 18 7 10 0 31 4 21
58 32 51 37 37 55 17 69 46 67
39 15 23 19 30 45 17 38 42 46
37 39 49 20 17 32 42 27 38 25
32 51 46 41 37 36 25 44 29 71
– 12 – 21 20 4 – 17 – 46
All values are presented as a percentage of patients per nursing home.
Discussion This study describes baseline characteristics, comorbidity, and the use of psychotropic drugs in a large group of patients with KS residing in special care units in Dutch LTCFs. In our study, all the reported patients had a history of chronic alcohol use and were relatively young, single men. The main finding in our study is the high percentage of prescribed psychotropic drugs and large differences in the prescription patterns among the participating nursing homes. Previous studies have reported a high comorbidity between psychiatric disorders and alcoholism (Petrakis et al., 2002; Kranzler and Rosenthal, 2003; Kessler, 2004). We are aware of only one
other study that reported psychiatric disorders in institutionalized patients with KS (Wijnia et al., 2012). The high percentage of users of a psychotropic drug in our study and differences in prescription patterns among the nursing homes can be partly explained by the percentage of patients with a psychiatric condition. Antipsychotics in particular were prescribed very often and more than one might expect on the basis of the available percentages of patients with a psychotic disorder. From experience, we know that behavioral symptoms, like agitation or aggression, are common in patients with KS. Behavioral symptoms and comorbid psychiatric conditions can be distressing to patients themselves and their environment. Several studies showed
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that behavioral symptoms in cognitively impaired nursing home patients are very common and that this leads commonly to more psychotropic drug use (Zuidema et al., 2007; Wetzels et al., 2011). More specifically, studies indicate that between 47% and 75% of nursing home residents with a DSMestablished dementia diagnosis are prescribed some type of psychotropic drugs (Pitkala et al., 2004; Selbaek et al., 2007; Eggermont et al., 2009). In the recent studies by Zuidema and Wetzels, patients were considered for inclusion provided they met the DSM-IV-TR criteria for dementia. There is the possibility that patients with KS were included in these studies and were not considered separately. Unfortunately in our study, a reliable description of behavioral symptoms was not possible since the participating nursing homes did not use assessments for behavioral symptoms in their charts. The effect of psychotropic drugs in the treatment of behavioral symptoms in patients with KS is largely unknown. Also behavioral symptoms can present as side effects of antipsychotics. Caregivers often experience behavioral symptoms of patients with KS as challenging and providing optimal management in which respect for the patient’s dignity is maintained requires expertise, empathy, and self-reflection. Our findings might indicate an overuse of psychotropic drugs to manage behavioral symptoms in patients with KS. One limitation of this study is the variation of criteria used in the facilities to diagnose KS. Moreover, because of uncertainty about diagnostic criteria, not all patients had been diagnosed with KS according to the DSM-disorder “alcoholinduced persisting amnestic disorder.” The term “alcohol-related dementia” or “alcohol-related brain damage” may cover this group, confirming the debate in the literature about the nosology of alcohol-related cognitive disorder (Gupta and Warner, 2008; Jauhar and Smith, 2009; Kopelman et al., 2009; Zahr et al., 2011). It is suggested that the alcohol amnestic (Korsakoff) syndrome forms a spectrum with other types of alcohol-related brain injury and thiamine depletion injury interacting with alcohol neurotoxicity resulting in “alcoholrelated brain damage” (Gupta and Warner, 2008; Jauhar and Smith, 2009; Kopelman et al., 2009; Zahr et al., 2011). The diagnosis KS requires increased validation through research and the development of diagnostic guidelines is necessary. Another limitation is the lack of diagnosis of cooccurring psychiatric disorders according to DSM-criteria. Furthermore, diagnosing psychiatric disorders in patients with KS is difficult because of the cognitive deficits. A valid diagnostic interview or assessment is not available. Careful psychiatric assessment in patients with KS is important, not
only from the perspective of scientific knowledge, but also because of clinical implications like treatment and prognosis. A strength of this study are the large sample size and the fact that the sample only concerns nursinghome patients with KS residing in special care units.
Conclusion This study shows baseline characteristics, comorbid conditions and use of psychotropic drugs in patients with KS residing in special care units in ten Dutch LTCFs. The use of psychotropic drugs is extensive with a great variation in prescription between the different nursing homes. More research is needed on the prevalence of behavioral symptoms and psychotropic drug prescription in patients with KS. Further research might develop the specific needs of care and experienced quality of life of this patients group.
Conflict of interest None.
Description of authors’ roles This study was initiated and designed by both authors. I. Gerridzen collected the data and wrote this paper. I. Gerridzen and A. Goossensen undertook the data analysis and interpretation. A. Goossensen was responsible for critical revision of the manuscript.
Acknowledgments Atlant Care Group, Nursing Home Markenhof, Beekbergen, the Netherlands, and the Dutch Korsakov Knowledge Centre supported this study. We would like to give special thanks for her comment to Ruth B. Veenhuizen, MD, PhD, VU University Medical Center, Amsterdam, the Netherlands.
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Patients with Korsakoff syndrome living in LTCFs Hague, The Netherlands. Acta Psychiatrica Scandinavica, 75, 604–607. Draper, B., Karmel, R., Gibson, D., Peut, A. and Anderson, P. (2011). Alcohol-related cognitive impairment in New South Wales hospital patients aged 50 years and over. Australian and New Zealand Journal of Psychiatry, 45, 985–992. Eggermont, L. H., de Vries, K. and Scherder, E. J. (2009). Psychotropic medication use and cognition in institutionalized older adults with mild to moderate dementia. International Psychogeriatrics, 21, 286–294. Galvin, R., Brathen, G., Ivashynka, A., Hillbom, M., Tanasescu, R. and Leone, M. A. (2010). EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. European Journal of Neurology, 17, 1408–1418. Gobert, M. and D’Hoore, W. (2005). Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland. International Journal of Geriatric Psychiatry, 20, 712–721. Gupta, S. and Warner, J. (2008). Alcohol-related dementia: a 21st-century silent epidemic? British Journal of Psychiatry, 193, 351–353. Harper, C., Gold, J., Rodriguez, M. and Perdices, M. (1989). The prevalence of the Wernicke-Korsakoff syndrome in Sydney, Australia: a prospective necropsy study. Journal of Neurology, Neurosurgery & Psychiatry, 52, 282–285. Jauhar, S. and Smith, I. D. (2009). Alcohol-related brain damage: not a silent epidemic. British Journal of Psychiatry, 194, 287–288; author reply 288. Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological Psychiatry, 56, 730–737. Kleijer, B. C. et al. (2009). The course of behavioral problems in elderly nursing home patients with dementia when treated with antipsychotics. International Psychogeriatrics, 21, 931–940. Kopelman, M. D. (1995). The Korsakoff syndrome. British Journal of Psychiatry, 166, 154–173. Kopelman, M. D., Thomson, A. D., Guerrini, I. and Marshall, E. J. (2009). The Korsakoff syndrome: clinical aspects, psychology and treatment. Alcohol & Alcoholism, 44, 148–154. Kranzler, H. R. and Rosenthal, R. N. (2003). Dual diagnosis: alcoholism and co-morbid psychiatric disorders. American Journal on Addictions, 12 (Suppl. 1), S26–40. Lovheim, H., Sandman, P. O., Kallin, K., Karlsson, S. and Gustafson, Y. (2006). Relationship between antipsychotic drug use and behavioral and psychological symptoms of dementia in old people with cognitive impairment living in geriatric care. International Psychogeriatrics, 18, 713–726. Nijk, R. M., Zuidema, S. U. and Koopmans, R. T. (2009). Prevalence and correlates of psychotropic drug use in Dutch nursing-home patients with dementia. International Psychogeriatrics, 21, 485–493.
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Oort, R. V. and 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, 78–81. Oslin, D., Atkinson, R. M., Smith, D. M. and Hendrie, H. (1998). Alcohol related dementia: proposed clinical criteria. International Journal of Geriatric Psychiatry, 13, 203–212. Petrakis, I. L., Gonzalez, G., Rosenheck, R. and Krystal, J. H. (2002). Comorbidity of alcoholism and psychiatric disorders. An overview. Alcohol Research and Health, 26, 81–89. Pitkala, K. H., Laurila, J. V., Strandberg, T. E. and Tilvis, R. S. (2004). Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards. International Psychogeriatrics, 16, 61–74. Schepers, J. P., Koopmans, R. T. and Bor, J. H. (2000). [Patients with Korsakoff’s syndrome in a nursing home: characteristics and comorbidity]. Tijdschrift voor Gerontologie en Geriatrie, 31, 113–118. Schneider, L. S., Dagerman, K. and Insel, P. S. (2006). Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. American Journal of Geriatric Psychiatry, 14, 191– 210. Selbaek, G., Kirkevold, O. and Engedal, K. (2007). The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes. International Journal of Geriatric Psychiatry, 22, 843–849. Sink, K. M., Holden, K. F. and Yaffe, K. (2005). Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA, 293, 596–608. Victor, M. (1994). Alcoholic dementia. Canadian Journal of Neurological Sciences, 21, 88–99. Wetzels, R. B., Zuidema, S. U., de Jonghe, J. F., Verhey, F. R. and Koopmans, R. T. (2011). Prescribing pattern of psychotropic drugs in nursing home residents with dementia. International Psychogeriatrics, 23, 1249–1259. Wijnia, J. W., van de Wetering, B. J., Zwart, E., Nieuwenhuis, K. G. and Goossensen, M. A. (2012). Evolution of Wernicke-Korsakoff syndrome in self-neglecting alcoholics: preliminary results of relation with Wernicke-delirium and diabetes mellitus. American Journal on Addictions, 21, 104–110. Zahr, N. M., Kaufman, K. L. and Harper, C. G. (2011). Clinical and pathological features of alcohol-related brain damage. Nature Reviews Neurology, 7, 284–294. Zuidema, S. U., Derksen, E., Verhey, F. R. and Koopmans, R. T. (2007). Prevalence of neuropsychiatric symptoms in a large sample of Dutch nursing home patients with dementia. International Journal of Geriatric Psychiatry, 22, 632–638.
Patients with Korsakoff syndrome in nursing homes: characteristics, comorbidity, and use of psychotropic drugs ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Ineke J. Gerridzen1 and M. Anne Goossensen2 1 2
Atlant Care Group, Nursing Home Markenhof, Beekbergen, the Netherlands University of Humanistic Studies, Utrecht, the Netherlands
ABSTRACT
Background: Very limited literature exists on the care and course of patients with Korsakoff syndrome (KS) living in long-term care facilities (LTCFs). Even less literature can be found on the pharmacological treatment of behavioral symptoms of KS. The purpose of the present study was to describe baseline characteristics, comorbidity, and the use of psychotropic drugs in institutionalized patients with KS. Methods: In this cross-sectional descriptive study, 556 patients were included living in ten specialized care units in Dutch nursing homes. Data were collected by means of a retrospective chart review. Results: The majority of patients were men (75%) and single (78%) with a mean age on admission of 56.7 years (SD 8.9, range 29.8–85.3). Mean length of stay was 6.0 years (SD 5.4, range 0.2–33.3). Sixty-eight percent of patients suffered from at least one somatic disease and 66% from at least one extra psychiatric disorder. One or more psychotropic drugs were prescribed to 71% of patients with a great variation in prescription patterns between the different nursing homes. Conclusion: Patients with KS depending on long-term care usually have comorbidity in more than one domain (somatic and psychiatric). The indications for prescribing psychotropic drugs are in many cases unclear and it seems probable that they are often given to manage challenging behavior. Longitudinal studies on the evidence for this prescription behavior and possible alternatives are recommended. Key words: Korsakoff syndrome, alcohol-related dementia, long-term care, nursing homes, comorbidity, psychotropic drugs, behavioral symptoms
Introduction Korsakoff syndrome (KS) is a chronic neuropsychiatric condition, characterized by a severe memory disorder resulting from acute Wernicke’s encephalopathy mostly secondary to chronic alcohol abuse and concomitant thiamine deficiency. In the Netherlands, there are specialized long-term care facilities (LTCFs) for patients with KS. Many institutionalized patients with KS show challenging behavioral symptoms like lack of awareness of the illness, aggression, sexual disinhibition, and apathy. These symptoms may lead to prescription of psychotropic drugs and put a heavy strain on caregivers. From studies of nursing home patients with dementia, it is known that a large percentage of patients have at least one behavioral symptom Correspondence should be addressed to: Ineke J. Gerridzen, MD, Elderly Care Physician, Atlant Care Group, Nursing Home Markenhof, Kuiltjesweg 1, 7361 TC Beekbergen, the Netherlands. Phone: +31-55-5067200; +31-651263852; Fax: +31-55-5067201. Email: [email protected]. Received 19 Dec 2012; revision requested 20 Jan 2013; revised version received 31 Jul 2013; accepted 7 Aug 2013. First published online 9 September 2013.
and despite modest effects and the risk of adverse effects, psychotropic drugs such as benzodiazepines, antipsychotics, and antidepressants are commonly prescribed in the LTCF setting (Pitkala et al., 2004; Gobert and D’Hoore, 2005; Sink et al., 2005; Ballard and Howard, 2006; Lovheim et al., 2006; Schneider et al., 2006; Selbaek et al., 2007; Eggermont et al., 2009; Kleijer et al., 2009; Nijk et al., 2009; Wetzels et al., 2011). Prevalence rates for behavioral symptoms and the use of psychotropic drugs in patients with KS residing in LTCFs might be even higher. However, institutionalized patients with KS have not been studied separately and extensively before and limited literature is available on the long-term care and course of this group of patients. Prevalence studies are out-of-date or scarce (Blansjaar et al., 1987; Harper et al., 1989; Kopelman, 1995; Schepers et al., 2000; Kopelman et al., 2009; Draper et al., 2011; Wijnia et al., 2012). Once institutionalized, the care needs of patients with KS are often not recognized adequately (Schepers et al., 2000). Often clear
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diagnostic criteria for KS are missing (Oslin et al., 1998; Galvin et al., 2010) and current diagnostic criteria for KS are mainly on clinical judgment. There is accumulating evidence that patients with KS have impairments in executive functioning. The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) (American Psychiatric Association, 1994) criteria for “alcohol-induced persisting amnestic disorder” do not take this into account (Oort and Kessels, 2009). The term alcoholic dementia is controversial and has generally been superseded by the concept of alcohol-related dementia, encompassing a broader definition of alcohol-related cognitive deficits (Victor, 1994; Oslin et al., 1998; Gupta and Warner, 2008). Some authors consider cases of alcohol-related dementia to be, in fact, KS (Victor, 1994; Oslin et al., 1998; Kopelman et al., 2009). The aim of this study was therefore: (a) to describe baseline characteristics and comorbidity and (b) to describe the use of psychotropic drugs in patients with KS residing in special care units in Dutch LTCFs.
Methods Participants In this cross-sectional descriptive study, 556 residents of ten special Korsakoff units in Dutch LTCFs were included. These facilities cooperate in a centre, which strives for developing knowledge, practice, and skills in the widest possible sense for patients with KS. This centre is called “the Dutch Korsakoff Knowledge Centre.” Participants were included when they had the following diagnoses reported in the medical chart: KS, Wernicke-Korsakoff encephalopathy, alcoholinduced persisting amnestic disorder, persistent cognitive impairment due to alcohol, alcoholinduced persisting dementia, and/or alcoholic dementia. Data collection All patient data were collected by one researcher (the first author) by means of a retrospective chart review. The investigation was performed on an arbitrary reference date during the period August 2011 to May 2012. The following data were retrieved from patients’ electronic administration files and medical charts: demographic data, patients’ representatives (legal and/or informal caregivers), admission dates, somatic and psychiatric comorbidity, and use of psychotropic drugs. The date of last admission was used in case there were multiple records. Somatic comorbid conditions were classified as follows:
COPD, cardiovascular diseases, hypertension, diabetes mellitus, cerebrovascular accident, epilepsy, and malignancy. Psychiatric comorbid conditions were classified as: mental retardation, psychotic disorders, mood disorders, anxiety disorders, personality disorders, other substance use disorders, and others. Suicide attempts, though not a DSMdisorder, were also registered. The prescribed psychotropic drugs were derived from patients’ prescription records and classified into three major categories: antipsychotics, antidepressants, and benzodiazepines. “As needed” (PRN) medication was not included. The use of these psychotropic drugs was compared to the prevalence of psychiatric diagnoses, which were mentioned in the medical charts. Analysis All demographic data, patients’ representatives (legal and/or informal caregivers), admission dates, somatic and psychiatric comorbid conditions, and prescriptions of psychotropic drugs were entered into a spreadsheet, using Microsoft Office Excel, version 14.1.0, 2010. The resulting database enabled descriptive analyses such as grouping and summarizing all data, calculating the mean and standard deviation (SD) and creating frequency tables and figures. Ethical and legal considerations Information about this study was provided to the patients or their representatives, the local client advisory boards and the management of the participating nursing homes. Although requesting patients’ informed consent was not necessary because of the retrospective nature of this study using only data from patients’ charts and processing these data anonymously into a large study group, patients or their representatives could refuse to participate. The local Research Ethics Committee at the Medical Centre of Leeuwarden approved the study.
Results In this study, no patients or representatives refused to participate. Baseline data was available for 556 patients with KS and are presented in Table 1. Mean age on admission was 56.7 years (SD 8.9, range 29.8–85.3) and most patients were men (75%). Mean age at reference date was 62.8 years (SD 8.4, range 40.8–85.8). The mean length of stay was 6.0 years (SD 5.4, range 0.2–33.3). Fifty-three percent of patients were divorced, 25% single, 9% still married, and 10% widowed. Nearly one-fifth of patients (19%) had a trustee or mentor as a legal representative. In only 3% of cases,
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Table 1. Patients’ characteristics (n = 556) CHARACTERISTIC
N (%
OF TOTAL POPULATION)
.......................................................................................................................................................................................................................
Gender male Mean age at reference date 80 years Mean length of stay at reference date 20 years Any somatic condition COPD Cardiovascular disease Hypertension Diabetes mellitus Cerebrovascular accident Epilepsy Malignancy Any psychiatric condition Mood disorders Psychotic disorders Personality disorders Suicide attempts Other substance use disorders Mental retardation Anxiety disorders Other psychiatric disorders
the trustee or mentor was a family member. 75% of patients had a relative as informal representative (partner 9%, child 26%, brother or sister 34%, nephew or cousin 2%, parent 4%, 6% a non-family member, and 2% no-one). Sixty-eight percent of patients suffered from at least one somatic comorbid condition. COPD (30%) and cardiovascular disease (25%) were common. Other comorbid conditions were: hypertension (16%), diabetes mellitus (16%), cerebrovascular accident (14%), epilepsy (14%), and malignancy (13%). Twenty-two patients (4%) had a malignancy of the oropharynx; 4 patients (1%) suffered from a lung carcinoma. More than half of the patients had at least one psychiatric comorbid condition (59%) as shown in Table 1. About twice as many had a mood disorder (32%) compared to the number with a psychotic disorder (18%). Personality disorders were mentioned in the medical charts in 15%. Suicide attempts were mentioned in 9%, mental retardation in 7%, and anxiety disorders in 6%. In addition to the alcohol abuse, there were also other substance use disorders (7%). Other comorbid
415 (74.6) 62.8 (SD 8.4) (range 40.8–85.8) 30 (5.4) 311 (55.9) 202 (36.3) 13 (2.3) 6,0 (SD 5.4) (range 0.2–33.3) 76 (13.7) 223 (40.1) 159 (28.6) 81 (14.6) 17 (3.1) 376 (67.6) 167 (30.0) 137 (24.6) 90 (16.2) 90 (16.2) 79 (14.2) 79 (14.2) 72 (13.0) 329 (59.2) 177 (31.8) 100 (18.0) 84 (15.1) 52 (9.4) 39 (7.0) 37 (6.7) 35 (6.3) 12 (2.2)
Table 2. Prevalence of psychotropic drug use (n = 556) TYPE OF MEDICATION
N (%)
........................................................................................................................................................
One or more psychotropic drug Type of psychotropic drug Antipsychotic Antidepressant Benzodiazepine Combination of drugs Antipsychotic + antidepressant Antipsychotic + antidepressant + benzodiazepine Antipsychotic + benzodiazepine Antidepressant + benzodiazepine
393 (70.7) 269 (48.4) 224 (40.3) 191 (34.4) 74 (13.3) 59 (10.6) 62 (11.2) 37 (6.7)
Note: All values in brackets are presented as a percentage of the total group.
conditions, which were found, were somatoform and eating disorders (2%). Table 2 shows the percentages of patients of the total group who were prescribed psychotropic drugs at reference date. Altogether nearly 71% of the
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Figure 1. Psychotropic drug use in percentages per nursing home.
residents were prescribed one or more psychotropic drugs. Twenty-nine percent used one type, 31% two types, and 11% at least three types of psychotropic drugs. Forty-eight percent of all patients used an antipsychotic drug, 40% an antidepressant drug, and 34% a benzodiazepine. Forty-two percent of all patients used a combination of two or three psychotropic drugs. In particular, the combination of an antipsychotic drug and an antidepressant drug was the most frequently prescribed combination (13%). Figure 1 shows the different prescription patterns of psychotropic drugs in the 10 LTCFs. The use of antipsychotics, antidepressants, and benzodiazepines varies per nursing home. Particularly in nursing homes VIII en X, nearly 70% of patients with KS used an antipsychotic drug. This contrasts with nursing home VII where only 17% of patients used an antipsychotic drug. The percentage of antidepressant users ranges between 25% (nursing home VII) and 71% (nursing home X). The percentage of benzodiazepine users ranges from 8% (nursing home VII) to 48% (nursing home III). In nursing home X, the percentages both of antipsychotic users (67%), antidepressant users (71%), and benzodiazepine users (46%) are high in contrast to nursing home VII (17%, 25%, and 8%, respectively). In general, antipsychotics were most frequently prescribed. Of the prescribed psychotropic drugs benzodiazepines were the least prescribed. Figure 2 combines percentages of patients with at least one psychiatric condition with the percentages
of at least one prescribed psychotropic drug per nursing home. The percentage of at least one prescribed psychotropic drug ranges from 33% (nursing home XII) to 83% (nursing home X). In contrast the percentage of patients with at least one psychotic disorder ranges from 47% (nursing home V) to 74% (nursing home III). The differences between the percentage of at least one prescribed psychotropic drug and the percentage of patients with at least one psychotic disorder strongly varies between nursing homes. In Table 3 the difference between percentages of users of a psychotropic drug and percentages of patients with a psychotic and a mood disorder are further specified per nursing home. Again, large differences are found between users of a psychotropic drug and patients with a psychiatric condition. For psychotic disorders, the differences between users of an antipsychotic drug and the disorder vary from 15% (nursing home II) to 46% (nursing home X). This suggests that patients with KS in nursing home X were prescribed antipsychotic drugs with an indication other than psychotic disorder more often than in nursing home II. For mood disorders, the differences are less striking. In four nursing homes, percentages of users of an antidepressant are even lower than percentages of patients with a mood disorder. Despite mood disorders occurring more often than psychotic disorders overall, antipsychotic drugs were prescribed more often than antidepressant drugs.
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Figure 2. Patients with ࣙ1 psychiatric condition and psychotropic drug use in percentages per nursing home.
Table 3. Use of a psychotropic drug in relation to indication in percentages per nursing home (n = 556)
NURSING HOME
PSYCHOTIC DISORDER
ANTIPSYCHOTIC DRUG
INDICATION OTHER THAN PSYCHOTIC DISORDER
MOOD DISORDER
INDICATION OTHER THAN ANTIDEPRESSANT MOOD DISORDER DRUG
............................................................................................................................................................................................................................................................................................................................
I II III IV V VI VII VIII IX X
19 17 28 18 7 10 0 31 4 21
58 32 51 37 37 55 17 69 46 67
39 15 23 19 30 45 17 38 42 46
37 39 49 20 17 32 42 27 38 25
32 51 46 41 37 36 25 44 29 71
– 12 – 21 20 4 – 17 – 46
All values are presented as a percentage of patients per nursing home.
Discussion This study describes baseline characteristics, comorbidity, and the use of psychotropic drugs in a large group of patients with KS residing in special care units in Dutch LTCFs. In our study, all the reported patients had a history of chronic alcohol use and were relatively young, single men. The main finding in our study is the high percentage of prescribed psychotropic drugs and large differences in the prescription patterns among the participating nursing homes. Previous studies have reported a high comorbidity between psychiatric disorders and alcoholism (Petrakis et al., 2002; Kranzler and Rosenthal, 2003; Kessler, 2004). We are aware of only one
other study that reported psychiatric disorders in institutionalized patients with KS (Wijnia et al., 2012). The high percentage of users of a psychotropic drug in our study and differences in prescription patterns among the nursing homes can be partly explained by the percentage of patients with a psychiatric condition. Antipsychotics in particular were prescribed very often and more than one might expect on the basis of the available percentages of patients with a psychotic disorder. From experience, we know that behavioral symptoms, like agitation or aggression, are common in patients with KS. Behavioral symptoms and comorbid psychiatric conditions can be distressing to patients themselves and their environment. Several studies showed
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that behavioral symptoms in cognitively impaired nursing home patients are very common and that this leads commonly to more psychotropic drug use (Zuidema et al., 2007; Wetzels et al., 2011). More specifically, studies indicate that between 47% and 75% of nursing home residents with a DSMestablished dementia diagnosis are prescribed some type of psychotropic drugs (Pitkala et al., 2004; Selbaek et al., 2007; Eggermont et al., 2009). In the recent studies by Zuidema and Wetzels, patients were considered for inclusion provided they met the DSM-IV-TR criteria for dementia. There is the possibility that patients with KS were included in these studies and were not considered separately. Unfortunately in our study, a reliable description of behavioral symptoms was not possible since the participating nursing homes did not use assessments for behavioral symptoms in their charts. The effect of psychotropic drugs in the treatment of behavioral symptoms in patients with KS is largely unknown. Also behavioral symptoms can present as side effects of antipsychotics. Caregivers often experience behavioral symptoms of patients with KS as challenging and providing optimal management in which respect for the patient’s dignity is maintained requires expertise, empathy, and self-reflection. Our findings might indicate an overuse of psychotropic drugs to manage behavioral symptoms in patients with KS. One limitation of this study is the variation of criteria used in the facilities to diagnose KS. Moreover, because of uncertainty about diagnostic criteria, not all patients had been diagnosed with KS according to the DSM-disorder “alcoholinduced persisting amnestic disorder.” The term “alcohol-related dementia” or “alcohol-related brain damage” may cover this group, confirming the debate in the literature about the nosology of alcohol-related cognitive disorder (Gupta and Warner, 2008; Jauhar and Smith, 2009; Kopelman et al., 2009; Zahr et al., 2011). It is suggested that the alcohol amnestic (Korsakoff) syndrome forms a spectrum with other types of alcohol-related brain injury and thiamine depletion injury interacting with alcohol neurotoxicity resulting in “alcoholrelated brain damage” (Gupta and Warner, 2008; Jauhar and Smith, 2009; Kopelman et al., 2009; Zahr et al., 2011). The diagnosis KS requires increased validation through research and the development of diagnostic guidelines is necessary. Another limitation is the lack of diagnosis of cooccurring psychiatric disorders according to DSM-criteria. Furthermore, diagnosing psychiatric disorders in patients with KS is difficult because of the cognitive deficits. A valid diagnostic interview or assessment is not available. Careful psychiatric assessment in patients with KS is important, not
only from the perspective of scientific knowledge, but also because of clinical implications like treatment and prognosis. A strength of this study are the large sample size and the fact that the sample only concerns nursinghome patients with KS residing in special care units.
Conclusion This study shows baseline characteristics, comorbid conditions and use of psychotropic drugs in patients with KS residing in special care units in ten Dutch LTCFs. The use of psychotropic drugs is extensive with a great variation in prescription between the different nursing homes. More research is needed on the prevalence of behavioral symptoms and psychotropic drug prescription in patients with KS. Further research might develop the specific needs of care and experienced quality of life of this patients group.
Conflict of interest None.
Description of authors’ roles This study was initiated and designed by both authors. I. Gerridzen collected the data and wrote this paper. I. Gerridzen and A. Goossensen undertook the data analysis and interpretation. A. Goossensen was responsible for critical revision of the manuscript.
Acknowledgments Atlant Care Group, Nursing Home Markenhof, Beekbergen, the Netherlands, and the Dutch Korsakov Knowledge Centre supported this study. We would like to give special thanks for her comment to Ruth B. Veenhuizen, MD, PhD, VU University Medical Center, Amsterdam, the Netherlands.
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