Willy Wonka's Wonderful and Wacky Bored Review!

Willy Wonka is a 78 year-old dude with a history of BPH, HTN, and mild dementia, brought in from the Chocolate Factory Assisted Living for the Sweet & Elderly, with a golden ticket from EMS saying he’s been acting even weirder than usual and stopped walking on his own.

Vital signs are normal, glucose 120, and he is afebrile. You approach him in the stretcher and notice he keeps talking to imaginary little orange Oompa Loompas and he smells of pee and candy. You see he has been incontinent of urine in the stretcher. His neuro exam is significant for being AOx1, but strength and sensation are grossly intact while supine. You get him to stand and try to make him walk, but it takes a full minute before he can initiate one wobbly step.

OK, you think, old geezer from a Nursing Home with altered mental status, trouble walking, and incontinence. Likely UTI, right?

Nope! UA is normal. CBC normal. CMP normal. CXR normal.

So… Now what?

Let's get a Head CT.

CT shows enlarged ventricles.

What's the likely diagnosis?

Normal Pressure Hydrocephalus! To clinch this diagnosis you need an LP with normal opening pressure and negative CSF studies, and you may see an improvement of symptoms after tapping out some CSF. Remember that great pneumonic from med school? Wet (incontinent), wobbly (gait disturbance) and wacky (dementia). Willy Wonka for the win!

A little more about this disease...

NPH (aka nonobstructing hydrocephalus or communicating hydrocephalus) is caused by increased accumulation of CSF, leading to ventriculomegaly. NPH is usually idiopathic occurring in older people, but can also occur after SAH or meningitis which interfere with CSF absorption. Gait disturbance can be mild (slow gait, shuffling) to severe (can’t initiate walking–called apraxia) . Dementia is caused by frontal lobe involvement, usually affecting memory and attention. Incontinence happens late in disease progression from both frontal lobe involvement and detruser instability.

Ddx should include other forms of dementia: Alzheimer’s, Lewy Body, Fronto-temporal, multi-infarct, and especially Parkinson’s with the gait issues. Also think about B12 or thyroid deficiency, syphilis, and depression in the elderly can present with dementia.

Treatment? VP shunt.

What presidential candidate looks the most like an Oompa-Loompa?

The Trumpster! Long hair, don’t care!