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.What's the likely diagnosis?
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.
References
Clinical Neurology, 9th ed. Ch 5, Dementia and Amnestic Disorders.
Ferri’s Clinical Advisor 2016
Tintinalli’s 7th ed.
By Dr. Kylie Birnbaum
Special Thanks to Dr. Willis and Doc Birnbaum, Senior
Kylie Birnbaum
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1 Comment
edenkim · August 12, 2015 at 8:18 pm
amazing alliteration: “Wet, wobbly and wacky. Willy Wonka for the win! “