Confusion & Unsteady Gait
This Physical Exam Tells You Why
July 11, 2024, by Rebecca Handler
Scenario:
A 70-year-old man is brought to the clinic by his family due to increasing confusion, difficulty walking, and urinary incontinence over the past few months.
Key Physical Findings:
- Wide-based, unsteady gait
- Positive Romberg test (loss of balance when eyes are closed)
- Mild cognitive impairment on mental status exam
Answer: Normal Pressure Hydrocephalus
The man is likely suffering from Normal Pressure Hydrocephalus (NPH), a condition characterized by an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles.
*In the image, the CSF spaces over the convexity near the vertex are narrowed (red circle), as are the medial cisterns (red circle) - these are typical findings of NPH.
Explanation:
Normal Pressure Hydrocephalus leads to enlarged ventricles that put pressure on the brain, causing the classic triad of symptoms: gait disturbance, cognitive impairment, and urinary incontinence.
Associated Symptoms:
- Shuffling gait
Slow movements
Memory problems
Difficulty concentrating
Pathophysiology:
NPH occurs when there is an imbalance in the production and absorption of cerebrospinal fluid, leading to its accumulation and increased pressure on the brain structures.
Diagnostic Approach:
- Clinical examination focusing on the characteristic triad of symptoms.
Brain imaging (MRI or CT scan) to visualize enlarged ventricles.
Lumbar puncture to measure CSF pressure and potentially improve symptoms temporarily.
Management:
- Ventriculoperitoneal (VP) shunt surgery to drain excess CSF and relieve pressure on the brain.
Physical therapy to improve gait and mobility.
Cognitive therapy to address memory and concentration issues.
Complications to Watch For:
- Shunt malfunction or infection
- Progressive cognitive decline
- Increased risk of falls and injuries
Case Outcome:
The man was diagnosed with Normal Pressure Hydrocephalus and underwent successful VP shunt surgery. His gait and cognitive symptoms improved significantly, and he regained independence in daily activities.
Other Common Findings in NPH:
- Slowness in performing daily activities
Decreased motivation or apathy
Difficulty with fine motor skills
Educational Points:
- Prevention: Regular monitoring for early signs of NPH in elderly individuals with risk factors.
- Awareness: Understanding the importance of timely diagnosis and treatment to improve quality of life.
By recognizing the symptoms of Normal Pressure Hydrocephalus through physical examination and patient history, healthcare providers can ensure timely intervention and improved outcomes for elderly patients.
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