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




  1. 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.



  2. Interpret and incorporate into the plan of care the results of cognitive and fall-risk outcome measures.



  3. 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.



No Image Available!




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











































































































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?

























































































































































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


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.






























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?

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Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Normal Pressure Hydrocephalus

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