Normal Pressure Hydrocephalus

General Information
Case no.	13.A Normal-Pressure Hydrocephalus
Authors	Stephen J. Carp, PT, PhD, Board Certified Clinical Specialist in Geriatrics Physical Therapy
Diagnosis	Normal-pressure hydrocephalus
Setting	Neuro step-down unit in an acute care hospital
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	List the common signs and symptoms of normal-pressure hydrocephalus pertinent to the physical therapist and discuss the rationale for the use of a ventriculoperitoneal (VP) shunt as a treatment option. Interpret and incorporate into the plan of care the results of cognitive and fall-risk outcome measures. Develop and defend the rationale for formulating an appropriate discharge plan for an acute care patient with multiple comorbidities and confounding social variables.

Medical
Chief complaint	Unsteady gait, change in mental status
History of present illness	A 72-year-old man admitted to the acute care hospital through the emergency department with a chief complaint of progressive unsteadiness of gait and change in mental status over the past few weeks. He is not very verbal, and most information is provided by his wife. He was ambulating well up to 2 to 3 months ago when he began to complain of unsteadiness while walking and began to lose his balance. Wife states he had no history of falls up to 1 month ago but since that time she has witnessed a progressive increase in the frequency of his falls. She states the falls occur at all times during the day and at night, inside and outside the home. She cannot identify a pattern to the falls. The patient has grudgingly begun to use a cane at home. Over the past 2 weeks, the wife has noted that her husband has been increasingly confused especially with recent events. He can no longer balance the check book. Twice in the past month he has become lost while driving (she has since taken his car keys). She has also noted that he has been incontinent of urine a number of times over the past 2 weeks and was incontinent of stool once. He also experiences urgency, increased frequency, and nocturia. The patient confirms his wife’s assessment about his mental status and loss of ambulatory balance but denies the urinary incontinence. They are both very worried that he has Alzheimer’s disease.
Past medical history	Diabetic retinopathy, diabetes mellitus type II (DM2), elevated cholesterol and lipids, high blood pressure, cervical arthritis
Past surgical history	Cholecystectomy: 20 years ago; appendectomy: 35 years ago
Allergies	latex, penicillin, seasonal allergies
Medications	Atorvastatin (Lipitor), Glipizide, Metoprolol succinate, Flonase prn for seasonal allergies
Precautions/orders	Fall risk, VP shunt Activity as tolerated

Social history
Home setup	Two-story home with five steps to enter home with rail on the right. Thirteen steps, rail on the left, to the second floor. Bed and bath on the second floor. No bathroom on the first floor. Has two married children residing within 30 minutes of home.
Occupation	Retired from accounting 3 years ago due to an increased frequency in work mistakes. Has master’s level education.
Prior level of function	Diminishment of function over past 3 months as evidenced by need to use walker or cane, frequent falls, decreased ability to perform hygiene, diminished social interaction. Assistance to climb steps. Independent with feeding, but requires assistance to bathe and occasionally to dress. Stopped driving 3 months ago secondary to “memory issues.”
Recreational activities	Wife reports that immediately after retirement, he exercised regularly, traveled, gardened, and performed woodworking but over the past 6 months most of these activities have diminished or ended. Over the past 3 months, his recreational activities have become limited to television watching.

Vital signs	Hospital day 0: neuro step-down unit
Blood pressure (mmHg)	130/90
Heart rate (beats/min)	82
Respiratory rate (breaths/min)	16
Pulse oximetry on room air (SpO₂)	97%
Temperature (°F)	98.7

Imaging/diagnostic test	Hospital day 0: Neuro step-down unit
Electrocardiogram (ECG)	1. Normal sinus rhythm. Rate 82. No ischemic changes
Magnetic resonance imaging (MRI)—brain	1. Mild cerebral and cerebellar atrophy, consistent with age, with otherwise normal-appearing gyri. 2. Dilated ventricles consistent with normal-pressure hydrocephalus. 3. Otherwise, normal MRI of the brain Fig. 13.1
MRI—cervical spine	1. Multilevel degenerative disk disease with degenerative joint disease at levels described above. 2. Posterior disk bulging with facet hypertrophy and uncovertebral joint spurring resulting in mild bilateral foraminal stenosis at C6–C7. 3. No significant cord impingement.

Fig. 13.1 The CT of the brain revealed mild cerebral atrophy and markedly dilated ventricles consistent with normal-pressure hydrocephalus. (Adapted from Kanekar S, ed. Neuroimaging. In: Imaging of Neurodegenerative Disorders. 1st ed. New York, NY: Thieme; 2015.)

Medical management	Hospital day 0: Neuro step-down unit	Hospital day 1: Neuro intensive care unit	Hospital day 2: Neuro step-down unit
Medications	1. Atorvastatin (Lipitor) 2. Glipizide 3. Metoprolol succinate 4. Flonase prn for seasonal allergies	1. Atorvastatin (Lipitor) 2. Glipizide 3. Metoprolol succinate 4. Flonase prn for seasonal allergies	1. Atorvastatin (Lipitor) 2. Glipizide 3. Metoprolol succinate 4. Flonase prn for seasonal allergies
Procedures	1. Lumbar puncture (LP)	1. LP results: fluid clear 2. Left VP shunt 3. Endotracheal tube placed for procedure 4. Insert foley catheter	1. Successful extubation with transition to nasal cannula (NC) 2. Remove foley catheter

Medical management

Hospital

day 0: Neuro step-down unit

Hospital

day 1:

Neuro intensive care unit

Hospital

day 2: Neuro

step-down unit

Medications

1. Atorvastatin (Lipitor)

2. Glipizide

3. Metoprolol succinate

4. Flonase prn for seasonal allergies

1. Atorvastatin (Lipitor)

2. Glipizide

3. Metoprolol succinate

4. Flonase prn for seasonal allergies

1. Atorvastatin (Lipitor)

2. Glipizide

3. Metoprolol succinate

4. Flonase prn for seasonal allergies

Procedures

1. Lumbar puncture (LP)

1. LP results: fluid clear

2. Left VP shunt

3. Endotracheal tube placed for procedure

4. Insert foley catheter

1. Successful extubation with transition to nasal cannula (NC)

2. Remove foley catheter

Lab		Reference range	Hospital day 0: Neuro step-down unit	Hospital day 1: Neuro intensive care unit	Hospital day 2: Neuro step-down unit
Complete blood count	White blood cell	5.0–10.0 × 10⁹/L	6.6	6.8	7.1
	Hemoglobin	14.0–17.4 g/dL	14.1	14.3	14.2
	Hematocrit	42–52%	42	42	42
	Red blood cell	4.5–5.5	5.1	5.2	5.2
	Platelet	140,000–400,000/μL	250	240	245
Metabolic Panel	Calcium	8.6–10.3 mg/dL	8.9	Not reordered	8.8
	Chloride	98–108 mEq/L	97		100
	Magnesium	1.2–1.9 mEq/L	1.8		1.8
	Phosphate	2.3–4.1 mg/dL	2.9		2.9
	Potassium	3.7–5.1 mEq/L	4.0		4.1
	Sodium	134–142 mEq/L	145		143
Other	Glucose	60–110 mg/dL	188	192	187
	Hemoglobin A1C	< 6% of total hemoglobin	7.1	–	–
	Folate	3.6–20 ng/dL	10.0	10.0	9.8
	Ferritin	13–300 ng/mL	130	130	131

Pause points
Based on the above information, what are the priority: Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priority:

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 2, Post-Op Day 1: Physical Therapy Examination
Subjective
Patient: “I am not really sure why I was admitted to the hospital. I think they sent me here because I was falling. You best ask my wife. My neck and head hurt. Did I have an operation? Was something done to my neck??” Wife: “I brought him here because I was very concerned that he has Alzheimer’ disease or something similar. Over the past 3 months, he has been getting progressively confused and withdrawn. He has been falling and he can’t control his urine. The neurologist here at the hospital ordered a lot of tests, which seemed to point toward a diagnosis of normal-pressure hydrocephalus. Yesterday morning, he had a shunt placed. The hope is the shunt decreases the amount of fluid in his brain, which hopefully will improve his symptoms.”
Objective
Vital signs	Pre-treatment			Post-treatment
Vital signs	Supine	Sitting	Standing
Blood pressure (mmHg)	132/76	130/74	132/78	134/78
Heart rate (beats/min)	76	80	86	88
Respiratory rate (breaths/min)	14	16	26	28
Pulse oximetry on 2 L NC (SpO₂)	98%	97%	98%	98%
Borg scale	1	3	4	4
Pain	3/10 (incision at neck)	4/10 (incision at neck)	4/10 (incision at neck)	3/10 (incision at neck)
General	Supine in bed, no acute distress Wife present at bedside Lines/equipment notable for peripheral intravenous (IV)
Head, ears, eyes, nose, and throat	Emerging ecchymosis at the surgical site on the left neck. Postoperative dressing clean/dry, intact
Cardiovascular and pulmonary	Vital signs as above No adventitious lung sounds Calves are without edema, tenderness, or rubor, and without palpable cords. Dorsalis pedis: 2 + bilaterally. Feet are warm
Gastrointestinal	Denies diarrhea or constipation Denies belly pain Endorses good appetite
Genitourinary	Endorses that he “wet the bed” this morning after foley catheter was removed. Denies hematuria, pain with voiding, foul-smelling urine
Musculoskeletal	Range of motion (ROM)	Cervical and lumbar spine ROM assessments deferred secondary to recent surgery. All articular ROM assessments are full and painless. No overt deformities noted.
	Strength	Bilateral upper extremity (BUE): grossly 4/5 throughout Bilateral lower extremity (BLE): grossly 4/5 throughout
	Aerobic	Aerobic testing deferred secondary to postoperative day 1.
	Flexibility	Articular ROM is normal and painless without deformity or pain. Two-joint muscle length testing deferred at this time.
	Other	No overt muscle wasting, or atrophy noted by visual inspection.
Neurological	Balance	Outcome measure	Presurgery	Postsurgery
		Montreal Cognitive Assessment (MoCA)	19/30	22/30
		Romberg—eyes open	12 seconds	14 seconds
		Romberg—eyes closed	8 seconds	12 seconds
		Timed Up and Go	16 seconds	13 seconds
	Cognition	See MoCA score above Alert and oriented × 3: unsure of surgical procedure Responds to questions but does not initiate conversation. Able to follow simple one-step commands.
	Coordination	Finger to nose: mild impairment in BUE Heel to shin: mild impairment in BLE
	Cranial nerves	I: intact olfactory sense bilateral via two stimuli. II: visual acuity 20/20 with corrective lenses, visual fields intact via confrontation. III, IV, VI: pupils equally reactive to light and accommodation. External ocular muscles intact. No ptosis noted. No twitches or flutters. No nystagmus noted. Pupils equal in size. Pupillary light reflex intact. V: intact sensation both sides of face via cotton and pin. Masseter and pterygoid muscles intact. VII: face symmetrical. Tongue sensation intact. VIII: hearing intact bilaterally. Negative signs of vestibular nystagmus. IX, X: palate elevates symmetrically. Gag reflex intact. Voice of normal amplitude. No hoarseness noted. XI: sternocleidomastoid and upper trapezius muscles intact. XII: tongue in midline. No atrophy or fasciculations noted.
	Reflexes	Biceps: 1 + /4 bilaterally Patellar: 1 + /4 bilaterally Clonus: (–) bilaterally Babinski: down-going bilaterally
	Sensation	BUE: intact to light touch BLE: intact to light touch, mild loss of vibratory sense from mid-calf to toe. Upper extremity drift test is positive bilaterally.
	Tone	BUE: rigid BLE: rigid Negative cogwheeling noted No intentional or resting tremor noted. No festination or difficulty initiating movement noted. No “freezing” of gait noted.
	Other	Dressing over left side of neck surgical site is clean, dry, and intact.
Functional status
Bed mobility	Rolling either direction: independent Scooting up in bed: minimal assistance Supine to/from sit: minimal assistance
Transfers	Sit to/from stand: minimal assistance Bed to/from chair: moderate assistance using stand pivot transfer to bedside chair with rolling walker.
Ambulation	Ambulated 2 × 10 feet with moderate assistance and rolling walker; significant verbal and tactile cuing for gait sequencing with assistive device. Gait deviations notable for mild LE ataxia, wide base of support, and multidirectional instability.
Stairs	Not applicable at this time.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I am really not sure why I am here. I want to go home with my wife and sleep in my own bed.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	Patient will be seen three to five times a week for therapeutic exercise, gait training, transfer training, endurance training, neuromuscular reeducation, patient and family education, and to facilitate discharge to appropriate care level.

Plan

☐ Physician’s

☑ Physical therapist’s

☐ Other’s

Patient will be seen three to five times a week for therapeutic exercise, gait training, transfer training, endurance training, neuromuscular reeducation, patient and family education, and to facilitate discharge to appropriate care level.

Bloom’s Taxonomy Level	Case 13.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Based on the physical therapy findings, determine and defend the discharge recommendation.
Analyze	5. Describe why removing cerebrospinal fluid via LP would decrease symptomology in a patient with normal-pressure hydrocephalus.
Apply	6. Design and implement two interventions for an ataxic gait pattern. 7. Design and implement two interventions for diminished standing balance.
Understand	8. What are the physical therapy implications for the home medications? 9. Why is it important to encourage cough and deep breathing in a postoperative patient?
Remember	10. What are the precautions of mobilizing someone day 1 post-VP shunt? 11. Define an ataxic gait pattern. 12. What are the symptoms of blood loss anemia? 13. Which of the three primary symptoms of normal-pressure hydrocephalus is often the least amenable for recovery by surgery?