A 68-year-old man is brought to the emergency department after a fall at home while walking to the kitchen. Prior to the fall, the patient did not have lightheadedness, chest pain, or palpitations, and he did not hit his head or lose consciousness during the fall or afterward. His wife says the patient has become increasingly weak over the past 6 months and has fallen several times. The patient has also become forgetful, and his wife thinks he even forgets to go to the bathroom, as he has urinated on himself on several occasions. He has a history of hypertension and osteoarthritis. The patient has never smoked but used to drink heavily until stopping 10 years ago. Blood pressure is 130/86 mm Hg and pulse is 80/min with no orthostatic changes. On physical examination, there is no carotid bruit, and cardiac examination is unremarkable. Neurological examination shows normal cranial nerves and fundoscopy. Bilateral lower extremity muscle strength is normal, but tone and reflexes are increased. Sensation to light touch, pain, and vibration are intact. Gait is slow and wide based, and the patient takes several small steps to turn around. Mini-Mental State Examination score is 21 of 30. Further evaluation of this patient is most likely to reveal which of the following findings?

Question

A 68-year-old man is brought to the emergency department after a fall at home while walking to the kitchen.  Prior to the fall, the patient did not have lightheadedness, chest pain, or palpitations, and he did not hit his head or lose consciousness during the fall or afterward.  His wife says the patient has become increasingly weak over the past 6 months and has fallen several times.  The patient has also become forgetful, and his wife thinks he even forgets to go to the bathroom, as he has urinated on himself on several occasions.  He has a history of hypertension and osteoarthritis.  The patient has never smoked but used to drink heavily until stopping 10 years ago.  Blood pressure is 130/86 mm Hg and pulse is 80/min with no orthostatic changes.  On physical examination, there is no carotid bruit, and cardiac examination is unremarkable.  Neurological examination shows normal cranial nerves and fundoscopy.  Bilateral lower extremity muscle strength is normal, but tone and reflexes are increased.  Sensation to light touch, pain, and vibration are intact.  Gait is slow and wide based, and the patient takes several small steps to turn around.  Mini-Mental State Examination score is 21 of 30.  Further evaluation of this patient is most likely to reveal which of the following findings?

Quizplus · Accepted Answer

Explanation: This elderly patient with recurrent falls and memory impairment has the classic symptom triad of normal pressure hydrocephalus (NPH): Gait dysfunction is often the most pronounced feature. Patients typically take small steps in a broad-based gait, often described as appearing that the feet are stuck to the floor (magnetic gait). Urinary incontinence is common and often of the urgency variety; however, incontinence with apathy occurs as the disease progresses. Dementia typically occurs slowly over a period of years and is associated with apathy and impaired executive function. Other common features include upper motor neuron signs (eg, hyperreflexia, spasticity, upgoing plantar reflexes). NPH is characterized by enlargement of the ventricles (ventriculomegaly) out of proportion to the sulci on neuroimaging (eg, CT scan, MRI). It is associated with reduced cerebrospinal fluid (CSF) reabsorption, which may occur due to elevated central pressures or chronic periventricular ischemia. The diagnosis is confirmed with improvement after high volume lumbar puncture or lumbar drain placement. As the name suggests, the cerebrospinal fluid opening pressure is normal; elevated pressures should alert the physician to other possible pathologies. The definitive treatment of NPH is placement of a ventricular shunt. (ventriculomegaly) (Choice A) This patient has a risk factor for vascular dementia (hypertension); however, the onset of vascular dementia typically occurs in a stepwise fashion (reflecting new strokes) rather than slowly progressive one. In addition, patients tend to have a narrow-based, shuffling gait. (Choice B) Cord compression from vertebral metastases can cause upper motor neuron signs and incontinence, but it is typically associated with severe back pain and progressive lower extremity weakness and paralysis. (Choice C) Pseudotumor cerebri is caused by elevated intracranial pressure (eg, elevated opening pressure on lumbar puncture). However, it is usually seen in young females with obesity and presents with headaches and double vision, not memory impairment; papilledema is expected on fundoscopic exam. (Choice E) Periodic sharp waves on electroencephalography are seen in Creutzfeldt-Jakob disease, which can cause upper motor neuron signs and ataxia but manifests with rapid-onset dementia and myoclonus. It is not commonly associated with urinary incontinence. (Choice F) Reactive VDRL on CSF analysis suggests neurosyphilis, which causes dementia but is often associated with pupillary abnormalities (eg, Argyll-Robertson pupils), sensory ataxia, and lancinating pains. It is very rare due to widespread antibiotic use. Educational objective: Normal pressure hydrocephalus is characterized by the symptom triad of gait disturbance, dementia, and urinary incontinence; upper motor neuron signs may also occur. Neuroimaging demonstrates enlargement of the ventricles out of proportion to the sulci.

A 68-Year-Old Man Is Brought to the Emergency Department After