Neuropsychiatric Alterations in a Patient Diagnosed with Advanced Korsakoff's Syndrome: Clinical Case of Low Incidence and Prevalence in Colombia

Korsakoff's syndrome (KS) is an insidious and progressive neuropsychiatric disorder that affects specific neurocognitive functioning, especially in tasks that require sustained attention, memory, executive functions, and visuospatial functioning. Usually, this disease generates neuropsychiatric complications that worsen the quality of life (QOL) of patients in the medium term. We present a case of a 63-year-old male who presented with a diagnosis of advanced Korsakoff's syndrome and has a clinical history of recurrent memory loss and a history of alcohol abuse. The patient showed difficulty manipulating immediate information, associated with a possible frontal lobe dysfunction, and inability to remember material given through the auditory pathway. The patient showed a psychiatric clinical picture which is constantly worsening his and his immediate caregiver's QOL. The data obtained demonstrate that the patient presents a progressive cognitive impairment, which in the short term is correlated with Korsakoff-type dementia. It is suggested to carry out functional neurorehabilitation plans aimed at improving the QOL of the patient, his immediate caregiver, and future people with this type of diagnosis.


Introduction
Korsakof's syndrome (KS) is a neuropsychiatric disease, also defned like a rest state after the encephalopathic disease phase of Wernicke's encephalopathy. KS is caused by the loss of vitamin B1 [1]. Its symptoms include the inability of the patient to form memories related to his immediate verbal memory and alterations in executive function tasks, especially in inhibition tasks. Te patient usually presented confabulation and visual and auditory hallucinations [2]. Other symptoms range from abnormal eye movements, motor incoordination, hypotension, elevated heart rate, and muscle weakness [1,2]. Te incidence of KS is higher in elderly subjects, and it is more prevalent in males. Te literature related to neuropsychological and neurobehavioral alterations secondary to a diagnosis of Korsakof's syndrome usually is insufcient; however, there are studies that reveal cognitive defcits in working memory and/or immediate verbal memory tasks.
Te treatment for KS consists of improving the patient's quality of life (QOL) immediately, controlling the symptoms, and avoiding the evolution or worsening of the disease [3]. According to diferent studies [2,3], the KS has an evolutionary and ultimately chronic process. Most of the patients who sufer from this disease usually end up with a clinical picture of Korsakof's dementia, which is accompanied by neurobehavioral disorders, disinhibition, irritability, social isolation, hallucinations, delusions of persecution, and aberrant motor behavior.
Other studies [4,5] demonstrate the existence of cognitive defciencies in comparison with control subjects, alterations to plan and control immediate behavior (executive functions), inability to consolidate information containing new learning (working memory), and the storage and recall of long-term memory; the neuroanatomical structures that are usually involved are the frontal lobe of executive nature, the temporal lobe (for the consolidation and evocation of information), and diencephalic structures such as the amygdala, hippocampus, hypothalamus, and frontosubcortical circuits [4]. Other fndings [6] demonstrate alterations in the execution of visuospatial and visuoconstructive tasks, language, emotional area, and personality [7]. Te aim of this work is to investigate the neuropsychiatric alterations presented by the patient with a diagnosis of advanced Korsakof's syndrome.

Case Report
Te case of a 63-year-old male patient, married, righthanded, occupation: industrial engineer, with higher education is reported. Te patient presented with recurrent memory loss without loss of consciousness, accompanied by a mixed clinical picture of depression with a greater prevalence of anxiety.
Te clinical history reveals an antecedent of alcohol abuse since the age of 16, related to a clinical evolution with apparent neurological defcit, aware, and oriented but with low verbal fuency. Te general examination showed no evident alterations, and his vital signs were normal, blood pressure 120/80 mmHg, pulse 80, and respiratory rate 20. Te patient takes losartan (every 12 hours) to treat his blood pressure and vitamin B1 (thiamine) to regulate his body.
In the neurological examination, the patient was conscious, aware, oriented in his individual, temporal and spatial sphere/dimensions, but with low verbal fuency, mild alterations in gait, difculty in taking a sequence of steps, and clinical bradypsychia.
Te MRI revealed widening of cerebral sulci at a cortical level (Figure 1(a)) volumetric reduction of brain tissue and involvement of superior frontal gyrus. In the sagittal section is observed atrophy in the marginal callosal fssure, widening of the paracentral sulcus, and atrophy in the superior frontal gyrus (seen from the medial side) (Figure 1(b)). Te image at the coronal slice (Figure 1(c)) revealed another temporal lobe involvement, especially in the lateral fssure or Sylvian fssure, with the left hippocampal atrophy involvement which is related to a defcit in consolidation processes and information storage.
We have a neuropsychology clinic protocol with the neuropsychological tests for the evaluation of the patient ( Table 1). Te direct score obtained in each of the tests has been considered, except for the DRS, in which the total score and the values of each of its subsections were considered. Table 2 shows the results of each of the neuropsychological tests.

Discussion
Te patient does not present clinical signs of depression. Te test score shows that there is no presence of low emotional reactivity; however, it has revealed a clinical picture of generalized anxiety. Te test results indicate that the patient presents a clinical picture of moderate-severe psychosocial stress, associated with movement, impatience, and motor fuctuations at the time of evaluation. Te patient is partially oriented in time, place, and space. Te results of the MMSE reveal alterations in memory tasks, inhibition tasks, and visuospatial functions. Te results are not within the expected range.
During the evaluation of the attentional functions, in the DRS and TMT's sections that evaluate attention tasks, the patient showed not being able to maintain the attentional focus (focused attention) on each of the stimuli presented ( Figure 2).
It has been identifed as a difculty for a behavioral response during the test; additionally, it has found the inability to process several stimuli at the same time; in this case, the patient cannot generate a response to one stimulus in the presence of others (TMT part A and B) (selective attention) (Figure 3). Similarly, there was no evidence of cognitive interferences that would impede the performance of the tests. Tese data show that the patient could present alterations in brain areas that are usually related to attention, especially in working memory tasks, generally correlated with the frontal lobe.
Te patient's memory has been assessed using the digit retention test, Babcock's story recall test, clock-drawing test, Rey's complex fgure test, and an immediate and delayed  It is a scale that aims to assess general cognitive aspects. It is an instrument with high validity for detecting clinical pictures of dementia. It has a total score of 144 points, grouped into 5 subsections: attention (37 points); initiative/perseveration (37 points); construction (6 points); conceptualization (39 points); memory (25 points)

Digit retention
Weschler scale digit retention: It is a subtest of the WAIS-IV that aims to measure the levels of attention and immediate verbal memory Trail making test (TMT) TMT-A: It is a paper and pencil test that aims to measure the levels of attention. Te patient must complete the test in the shortest possible time. TMT-B: Te subjects must match numbers from 1 to 25 consecutively, and executive functions which consists of matching numbers from 1 to 13, but alternating with letters (1A-2B-3C-4D-5D and so on consecutively). Te patient must complete the test in the shortest possible time.
Babcock's story recall test It aims to assess verbal and delayed memory. Te test is presented by the auditory pathway. Rey's complex fgure.

Rey complex fgure
It is a screening test or brief cognitive tracking; its objective is to evaluate cognitive functions in patients with neurological or neurodegenerative diseases. It is a test that aims to assess visuospatial memory and visuomotor ability.

Te clock-drawing test
It is a screening test or brief cognitive tracking; its objective is to evaluate cognitive functions in patients with neurological or neurodegenerative diseases. It is a test that aims to assess visuospatial memory and visuomotor ability.

Memory test
It is a test that aims to assess immediate and delayed verbal memory. A series of words is read to the patient; then, he must verbalize them. After a while, the patient is asked to remember the list of words.
Brief frontal assessment battery (FAB) It is a specifc test that measures executive functioning and cognitive defcits or low performance in older adults or those diagnosed with a neurodegenerative disease.

Verbal fuency
Te patient presented with a task where he has to name animals and common names in one minute. Furthermore, it can also be performed alternately, when the subject must name a word, alternating it with a category required by the evaluator. Te score is obtained by the sum of the correct answers.

Barthel index
It is a questionnaire that aims to evaluate and assess the level of functional independence of the patients, during basic activities of daily living.

Lawton and Brody
It is a questionnaire that assesses the level of functional independence of the subjects to perform instrumental activities of daily living.
Health self-perception questionnaire (GHQ-28) It is a questionnaire that evaluates health and self-perception of health in subjects with diferent clinical conditions. Te questionnaire is grouped into four sections of seven items (somatic symptoms, anxiety/insomnia, social dysfunction, and depression). A score greater than or equal to 23 points is a possible indicator of a psychiatric condition.
verbal memory task. During the evaluation, the patient presented severe difculty to process immediate information; this has been revealed by the use of material that stimulates short-term memory; additionally, he showed to not be able to retain new information or generate new learning. Te digit retention test revealed a very low score; therefore, the patient could present an inability to manipulate information in situations which require quick decisions. Te patient is not able to remember the information immediately given. Tis type of memory has been evaluated by Babcock's story recall test. Te test revealed that the patient presents difculty to explain the verbal material presented by the auditory pathway; moreover, he did not present the cognitive skills necessary to register, encode, consolidate, and recover the information previously given. Similarly, in Rey's complex fgure test, a test was presented visually; the patient demonstrates to be unable to complete the fgure presented on the test; then, in the memory test, he could not perform it. Tese results suggest a serious difculty related to short-and long-term memory in tasks of visuospatial functioning and visuoconstructive skills. Despite the results of the copy, the patient defnes some details, but it is not enough for the expected range for his age.
Tese results are confrmed by the DRS's memory subsections, which revealed the lack of skills or cognitive strategies in the patient to process, consolidate, and recall information. Te scores obtained are below the expected. Similarly, in the memory test, a low score has been obtained, which confrms an inability in working memory tasks and short-and long-term memory tasks, thereby, preventing the preservation of the mnesics content and dysfunction of brain structures associated with memory such as the neurocognitive domain. In the clock-drawing test, it was also identifed (in command and copy) that there is no visual and motor organization to reproduce, store, and recall the task (Figure 4).
From executive functions results, it was found that the patient presents an inability to plan, organize, and regulate his immediate behavior. Te DRS revealed that the patient lacks motor, cognitive, and behavioral functions to perform activities that require intentionality, control, and behavior in the execution of a task, the same situation is for the FAB; although the score is very low and may denote a clinical picture of dementia, because of his age and the presence of KS, it cannot be delimited in this way, a similar situation is for the DRS. Te explanation for this data is that the patient s disease is still evolving, generating a clinical picture of cognitive defcit, which is represented by a corticosubcortical atrophy, that afects the cognitive domains previously explained. In this case, the domain afected is verbal fuency because the patient did not present the mental and oral fexibility to generate common names, animals, and both in an alternating state. Tese data are possibly related to the dysfunction in his frontal lobe and dorsolateral cortex.
Regarding the basic and instrumental activities of daily living, the Barthel index revealed that the patient is independent; nevertheless, these data have not been confrmed by the Lawton and Brody scale, which revealed that the patient is entering a phase of dependence that needs to be assessed immediately, since it may be an indicator of progressive cognitive impairment, which as the disease evolves, may be refected in a clinical picture of dementia.

Conclusion
Te results indicate that the patient presents neuropsychological alterations in neurocognitive domains, such as attention, because the patient is not able to retain the attentional focus, or to manipulate the information when presented with diferent stimuli [6]. Te data obtained by diferent studies [4][5][6] indicate that patients with KS usually present severe problems in the storage, processing, consolidation, and evocation of information, as occurs with the case report. Te patient showed difculty generating new memories; his mental processes in relation to brain structures in the storage of information do not allow the condensation and recovery correlated with the immediate operative and/or verbal memory. Also, the deferred verbal memory showed to be altered [6] because the patient demonstrates to be unable to access previously learned memories, a situation that usually gets worse during the evolution of the disease; therefore, it requires immediate and multidisciplinary attention.
In executive functioning tasks, it has been found that serious difculties regulate and control the immediate behavior; the age and KS that the patient sufers are directly correlated with the cortico-subcortical atrophy that he is presenting, which causes a lower performance in tasks that require cognitive fexibility, conceptualization, and the defnition of clear goals or objectives [5,6]. Unfortunately, the patient showed to be unable to generate a behavioral pattern that is accompanied by a new response, and against a variety of stimuli, his low verbal fuency demonstrates the inability to have executive control, anticipation, action, and planning to perform certain motor behaviors having a clear and specifc purpose. Tese alterations may be related to a dysexecutive syndrome [6,7]. Tese neuropsychological defcits are correlated with frontal hypometabolism in positron emission tomography (PET) [8].
Regarding the activities of daily living, the patient is moderately independent; however, by making errors such as confuse the denomination of money and forget the consumption of his medications, suggest and even afrm, that in a short time, the clinical picture of the patient could progress to Korsakof-type dementia, which is linked to the score he obtained in the GHQ-28. Currently, the patient presents a neuropsychiatric episode where he does not recognize his disease, accompanied by the chronicity of each of his symptoms, especially in anxiety and less in depression. For this reason, it is a necessary multidisciplinary intervention, which comprises specialties such as internal medicine, psychology, neuropsychology, neurology, physiotherapy, and occupational health, which have a clear objective, the improvement of his QOL [9][10][11][12][13][14].
Based on the results obtained, it can be inferred that the patient in the medium term will present a progressive neurocognitive defcit associated with a possible clinical picture of dementia due to KS. It is considered necessary to carry out prevention campaigns focused on Korsakof's disease, with the purpose of preventing major neuropsychological alterations in patients with this type of diagnosis. Also, neurorehabilitation plans by expert neuropsychologists become a unique opportunity to improve the quality of life in patients with this disorder. Future lines of research should focus on functional neurorehabilitation plans aimed at the early diagnosis and treatment of this disease, accompanied by epidemiological studies focused on the study of the incidence and prevalence of this disease.

Data Availability
Te neuroimages data and test applied during the assessment that support the fndings of this study are included within the article. Any other data related to this research are   Case Reports in Medicine available from the corresponding author on reasonable request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.