Mental State Examination
Obese and mildly dishevelled woman with marked psychomotor slowing.
Normal external eye movements.
Wide-based "magnetic" gait with mobility aided by 4 wheel frame.
Speech slow and diminished in prosody.
Mood euthymic, affect blunted in quality and restricted in range.
No formal thought disorder.
Anxious conversational themes focussed on cause of falls and fear of nursing home placement.
No suicidal ideation.
No delusions or hallucinations.
Good insight into premorbid psychiatric illness and more recent cognitive deterioration.
This case demonstrates the classical clinical presentation and neuroimaging findings of normal pressure hydrocephalus (NPH). Of special note are the clearly demonstrated CSF flow voids on T2-weighted imaging.
While VP shunting does not always improve the clinical syndrome associated with this disease, the presence of elevated CSF flow in the aqueduct is considered the best non-invasive predictor of a favourable outcome to shunting, although even this is debated.
This particular patient enjoyed a significant functional improvement in each of the key domains of mobility, continence and cognition with surgical intervention, and was able to avoid both nursing home placement and a diagnosis of young-onset dementia.
The case also demonstrates the utility of seeking potentially reversible causes of neuro-cognitive decline, and avoiding the attribution of functional decline to mental illness in an otherwise well-treated patient.