A 79-year-old man comes to the physician with his daughter for memory loss over the last 8-12 months. She initially noticed that he had trouble with forgetfulness, followed by distractibility and difficulty with word finding and object recognition. The patient is currently dependent on her for most independent activities of daily living, including transportation and finances. He is able to dress, bathe, and toilet himself. His gait has been unstable, and he sometimes seems to get "stuck in a chair." On review of systems, he notes urinary urgency, frequency, and incontinence. He has a history of benign prostatic hyperplasia for which he takes tamsulosin. The patient has no tremor, problems with sleep, weakness, hallucinations, or sensory disturbances. On examination, his vital signs are normal. He is oriented to self only. On mental status examination, he has impairments in language, visuospatial skills, and executive function. His cranial nerves are intact. There is normal bulk and tone of the musculature. His gait is wide based and magnetic. He has decreased stride length and a slow turn requiring several steps. Laboratory results, including TSH and vitamin B12, are normal. Brain imaging is shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Question

A 79-year-old man comes to the physician with his daughter for memory loss over the last 8-12 months.  She initially noticed that he had trouble with forgetfulness, followed by distractibility and difficulty with word finding and object recognition.  The patient is currently dependent on her for most independent activities of daily living, including transportation and finances.  He is able to dress, bathe, and toilet himself.  His gait has been unstable, and he sometimes seems to get "stuck in a chair."  On review of systems, he notes urinary urgency, frequency, and incontinence.  He has a history of benign prostatic hyperplasia for which he takes tamsulosin.  The patient has no tremor, problems with sleep, weakness, hallucinations, or sensory disturbances.  On examination, his vital signs are normal.  He is oriented to self only.  On mental status examination, he has impairments in language, visuospatial skills, and executive function.  His cranial nerves are intact.  There is normal bulk and tone of the musculature.  His gait is wide based and magnetic.  He has decreased stride length and a slow turn requiring several steps.  Laboratory results, including TSH and vitamin B12, are normal.  Brain imaging is shown in the image below.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c000_7af0_8f63_c175a900124d_MD0005_00 This patient's presentation is consistent with a likely diagnosis of normal-pressure hydrocephalus (NPH). NPH is characterized by the classic triad of gait disturbance followed by impaired cognition and urinary incontinence. Gait is usually wide based and can be described as being magnetic due to the appearance of the feet being stuck to the floor. Cognitive impairment usually follows gait dysfunction and can include early psychomotor slowing and problems with executive function (eg, financial planning). Urinary incontinence is typically a late manifestation and should raise suspicion in this patient as he is already on treatment for benign prostatic hyperplasia. Typical findings on brain imaging include ventriculomegaly out of proportion to sulcal enlargement and the absence of an obstruction. Patients with a supportive history and ventriculomegaly on neuroimaging should first undergo lumbar drainage of cerebrospinal fluid (CSF). The lumbar tap test (Miller Fisher test) evaluates parameters such as gait speed, stride length, verbal memory, and visual attention before and after removal of 30-50 mL of CSF. Patients with improvement in any of the parameters have a high probability of responding to definitive treatment with ventriculoperitoneal (VP) shunt placement (Choice E). If there is no improvement with CSF drainage, VP shunting may not be very helpful. (Choice A) There is limited data on the efficacy of acetazolamide in the treatment of NPH and it is not currently recommended. (Choice B) Carbidopa-levodopa can be used to treat Parkinson disease, which is characterized by bradykinesia, resting tremor, and postural instability. Although this patient has a magnetic gait and slow movement, his lack of tremor or rigidity on neurologic examination and the presence of dilated ventricles on MRI make NPH more likely. (Choice C) Donepezil is an acetylcholinesterase inhibitor that can improve cognitive function and activities of daily living in patients with various forms of dementia (eg, Alzheimer disease, vascular dementia, dementia with Lewy bodies). There are no major studies evaluating the efficacy of donepezil in the treatment of NPH, the primary treatment of which is VP shunting. Educational objective: Normal-pressure hydrocephalus typically presents with the classic triad of gait disturbance followed by impaired cognition and urinary incontinence. Neuroimaging with MRI should demonstrate ventriculomegaly out of proportion to sulcal enlargement and the absence of an obstruction. Lumbar drainage of cerebrospinal fluid with pre and post assessment of gait and cognition is helpful in predicting the effectiveness of ventriculoperitoneal shunting. References: Diagnosis and management of idiopathic normal-pressure hydrocephalus. (http://www.ncbi.nlm.nih.gov/pubmed/24175154)

A 79-Year-Old Man Comes to the Physician with His Daughter