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B12 supplementation
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Donepezil
Measurement of serum TSH concentration
Serial lumbar puncture with ventriculoperitoneal shunt placement
Trihexyphenidyl
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This patient is presenting with new-onset dementia with associated gait apraxia and urinary incontinence. This is a classic presentation of normal pressure hydrocephalus (NPH), which is best managed with serial lumbar puncture (LP) and eventual ventriculoperitoneal (VP) shunt placement. NPH results from a decrease in reabsorption of cerebrospinal fluid (CSF) at the arachnoid granulations, resulting in a communicating hydrocephalus. This leads to enlargement of the ventricles and as a result, fibers of the corticospinal tract in the corona radiata, as well as the cerebral cortex are compressed. This leads to the classic triad of gait apraxia, urinary incontinence and dementia. Patients are often very responsive to serial LPs and VP shunt placement. With treatment, symptoms of NPH (including dementia) are often reversible. Oliviera et al. review the pathophysiology, clinical presentation, diagnosis, and management of NPH. They describe the classic triad of gait apraxia, dementia and urinary incontinence, and discuss management to include serial LPs and VP shunt placement. Incorrect Answers: Answer 1: Vitamin B12 deficiency may present with symptoms of dementia. Patients often have associated peripheral neuropathy and megaloblastic anemia. This patients dementia with associated urinary incontinence and gait apraxia are more suggestive of NPH. Answer 2: Donepezil, an acetylcholinesterase inhibitor, is often used in the management of Alzheimer dementia. This patient's associated urinary incontinence and gait apraxia would be unusual in Alzheimer dementia and are more suggestive of NPH. Answer 3: Measurement of serum TSH concentration would be useful in identifying hypothyroidism, which may be a cause of reversible dementia. Urinary incontinence and gait apraxia would be unusual and are more suggestive of NPH. Answer 5: Trihexyphenidyl is used in the management of Parkinson disease, which may present with gait apraxia similar to this patient. However, associated dementia and urinary incontinence in an elderly patient is more suggestive of NPH.Bullet Summary:The management of normal pressure hydrocephalus includes serial lumbar punctures and ventriculoperitoneal shunt placement.
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