A 72-year-old man is brought to the office by his niece due to medication nonadherence. The patient has type 2 diabetes mellitus that had been well controlled with a basal-bolus insulin regimen, but recently he has not been taking his insulin regularly and his home glucometer readings have been high. In the past, he self-administered his insulin without difficulty, but now he no longer knows how to draw up his insulin or inject it. The patient's niece says he has been "letting things go" around the house since his wife's death from cancer 3 years ago. He is also reluctant to leave the house after a fall several months prior, and his family has had to help him with grocery shopping and other common errands. On physical examination, the patient appears unkempt and his clothes smell of urine. The lungs are clear on auscultation and heart sounds are normal. The abdomen is soft and nontender. Neurological examination reveals absence of bilateral ankle reflexes, and the patient's gait is slow with a wide base. Brief cognitive assessment shows short-term memory impairment. Hemoglobin A1c is 10.2%. Which of the following is the best next step in the management of this patient?

Question

A 72-year-old man is brought to the office by his niece due to medication nonadherence.  The patient has type 2 diabetes mellitus that had been well controlled with a basal-bolus insulin regimen, but recently he has not been taking his insulin regularly and his home glucometer readings have been high.  In the past, he self-administered his insulin without difficulty, but now he no longer knows how to draw up his insulin or inject it.  The patient's niece says he has been "letting things go" around the house since his wife's death from cancer 3 years ago.  He is also reluctant to leave the house after a fall several months prior, and his family has had to help him with grocery shopping and other common errands.  On physical examination, the patient appears unkempt and his clothes smell of urine.  The lungs are clear on auscultation and heart sounds are normal.  The abdomen is soft and nontender.  Neurological examination reveals absence of bilateral ankle reflexes, and the patient's gait is slow with a wide base.  Brief cognitive assessment shows short-term memory impairment.  Hemoglobin A1c is 10.2%.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d300_6ce8_bc81_03f0599f42af_MD0003_00 This elderly patient with cognitive impairment, urinary incontinence, and gait abnormalities (eg, slow, wide-based) has the classic symptom triad of normal pressure hydrocephalus (NPH). NPH is a potentially reversible cause of dementia characterized by the abnormal accumulation of cerebrospinal fluid. It is often idiopathic and occurs most commonly in older adults (age >60). However, it may occur in any age group due to neurologic trauma, infection, or subarachnoid hemorrhage resulting in scarring of the arachnoid granulations. Although upper motor neuron signs may occur in advanced disease, many elderly patients have diminished lower extremity reflexes (eg, ankles) related to age. Neuroimaging (eg, MRI, CT scan) shows ventriculomegaly out of proportion to the sulci. The diagnosis is confirmed with lumbar puncture, which demonstrates normal opening pressure and transient clinical improvement following high-volume cerebrospinal fluid removal. Definitive therapy is a ventriculoperitoneal shunt. ventriculomegaly out of proportion to the sulci (Choice A) Although nursing home placement may eventually be required for patients with progressive dementia, this patient's presentation suggests NPH, which is potentially reversible and should be evaluated with MRI. (Choice B) Depression can cause apathy and signs of cognitive impairment ("pseudodementia"), but patients typically have other depressive symptoms (eg, sleep impairment, depressed mood) as well. Treating depression without working up the patient's focal findings would likely lead to progression of dementia. (Choices C and E) Changing to an oral diabetic regimen and providing patient and family education could be considered after workup and diagnosis of this patient's cognitive decline. However, diagnosis and treatment of NPH should take priority. Educational objective: Normal pressure hydrocephalus is a potentially reversible cause of dementia characterized by cognitive decline, gait impairment, and urinary incontinence. Neuroimaging demonstrates ventriculomegaly out of proportion to the sulci.

A 72-Year-Old Man Is Brought to the Office by His