Your friend calls you sounding weak and confused. Out of concern, you stop over to find she barely recognizes you. You take her to the hospital, where doctors proceed to run tests and realize — as EMS is helping her into the ambulance — she seems to have trouble coordinating her steps.
What could have possibly happened to your friend?
We often think of a nutritional deficiency as something that happens only in dire situations, like visible starvation. However, in the case of thiamine deficiency, the person may appear healthy, but be starving for this particular nutrient. It can be persuasively argued that for most of the 35 million patients admitted to U.S. hospitals annually, thiamine deficiency should be screened for and, if present, treated.
When advocating for someone with this deficiency, the below information could be lifesaving:
What Is Thiamine?
Thiamine, also known as vitamin B1, is an essential nutrient, meaning that our bodies cannot make it — and therefore, thiamine must be consumed as part of our diet. Without thiamine, people cannot break down carbohydrates and proteins properly, depriving the body of needed energy and cellular building blocks. If untreated, thiamine deficiency can lead to irreversible brain damage, including the inability to form new memories. If severe enough, thiamine deficiency is fatal.
Thiamine’s History as Part of the Problem
In 1881, anatomist and neuropathologist Carl Wernicke observed the following symptoms in chronic alcoholics:
— Confusion
— Dysfunction of the eye muscle
— Lack of balance while walking
Although this triad was discovered by Dr. Wernicke and named Wernicke’s Encephalopathy in his honor, the cause of these debilitating symptoms would remain unknown for another 50 years.
When it was determined that the cause was thiamine deficiency, it soon became standard in medical treatment to examine alcoholics for the triad — and if all three were found, to give patients thiamine.
Why Your Loved One Might Not be Getting theThiamine He or She Needs
Medical students memorize these three symptoms as the “The Triad” and know to look for it in patients who have alcoholism. If you are an alcoholic and have all three of these symptoms, you are luckier than many patients, because every doctor will make the right diagnosis and get you the vitamin supplementation you need.
The problem is that very few patients, less than 25 percent, will present with all signs of the triad. Also, many physicians unfortunately only look for thiamine deficiency in patients who are known alcoholics, when it is known today that many conditions can cause a thiamine deficiency, including:
— Cancer
— Infection-causing fever
— Morning sickness (hyperemesis gravidum)
— Liver dysfunction
What Can You Do?
If you have a loved one who has been admitted to the hospital, ask his or her doctor if they have considered thiamine deficiency as a part of the clinical picture. If the doctor tells you that the patient you are asking about is not an alcoholic and does not have “The Triad,” encourage the doctor to use the Caine criteria for thiamine deficiency. The Caine criteria are two or more of the following:
— Confusion
— Dysfunction of the eye muscle
— Lack of balance while walking
— Risk of nutritional deficiency
Having two of the four criteria will identify 85 percent of patients of who are thiamine deficient.
If the physician is open to thiamine deficiency in the hospitalized patient, your advocacy is not done yet. Many prescribers who are not aware of thiamine absorption (it is not a topic that is widely taught in medical schools) will prescribe thiamine tablets and call it a day. When someone is thiamine deficient, oral thiamine will never be able to replenish effectively. Ask the doctor to give the patient intravenous or intramuscular thiamine several times daily for at least three days.
What Can Hospitals Do Better?
Very few presentations fundamentally change the way one practices medicine. Montefiore Health System’s residency in psychiatry alum, Dr. Elie Isenberg-Grzeda, who has dedicated much of his early career to expanding the proper repletion of thiamine, recently gave a transformative presentation at our Grand Rounds. With compelling clinical cases, he convinced the audience to think about thiamine deficiency and replenishment in conditions other than alcoholism.
At Montefiore, we are also lucky to have two physicians who have led one of the most successful efforts at thiamine replacement in the country. Drs. Jonathan Wai and Christopher Aloezos have developed an electronic order set to allow other physicians to click three buttons and properly replete thiamine in all of their hospitalized patients who, according to the Caine criteria, are at risk of thiamine deficiency. Many of us have observed patients who we would have possibly concluded had irreversible deficits, like those seen in dementia, to have reversible findings when treated with proper doses of intravenous thiamine. As Drs. Wai and Aloezos have accomplished all of this while still in residency, there is a likelihood that these brilliant, dedicated and computer savvy physicians will increase thiamine repletion throughout hospital systems for years to come.
Physicians must be educated on thiamine, thiamine deficiency and thiamine repletion in order to increase proper management.
Until doctors are educated more completely, you are now armed with the knowledge that could save the brain — if not the life — of someone you love.
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How to Recognize and Treat Thiamine Deficiency originally appeared on usnews.com
