A 56-year-old woman brings her 78-year-old father to the emergency room. The patient complains that sometimes he can't think straight
His daughter reports that her father has been "tripping over his own feet" and has become incontinent of urine in the last few days. The patient's medications include an ACE inhibitor and beta blocker. On physical examination, vital signs are within normal limits, heart and lungs show no abnormalities, cranial nerves are intact, and sensation and muscle strength are normal. A mental status exam is normal. Imbalanced gait and a positive Romberg test are apparent. Which of the following are possible disorders?
A. Cerebellar dysfunction
B. Normal pressure hydrocephalus
C. Early dementia
D. A & B
ANS: D
Normal pressure hydrocephalus is not fully understood. It is seen primarily in persons over 60 years of age and involves enlargement of the ventricles, often without increased CSF pressure; intraventricular pressures may be high or normal. One of the theorized causes includes intermittent pressure increases. It is slightly more common in men than in women. The patient often first notices some degree of gait disorder, followed by the onset of a "clouding" of thought processes, which gradually progress. The typical picture is a patient who has a triad of gait disturbance, altered thought processes, and urinary incontinence. Strength and sensation are usually within normal limits. However, focal neurological findings are present and include increased deep tendon reflexes, the inability to tandem walk, positive Babinski, and/or positive Romberg.
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