An 88-year-old woman presents with her son to her primary care physician for evaluation of confusion. Her son reports that she has had a progressive worsening of memory over the last year as well as increased falling. Past medical history is significant for hypertension and type 2 diabetes mellitus and she has not had any recent changes to medications. Memory testing reveals deficits in short-term memory and executive functioning. Physical examination reveals that when she walks, she moves slowly, takes small steps, and has a wide base. MRI of the brain is significant for ventricular enlargement out of proportion to cerebral atrophy.
Which of the following additional features is most likely present in this patient?
D) Urinary incontinence
The patient’s symptoms, clinical features, and imaging findings are consistent with normal pressure hydrocephalus, which presents with the classic triad of confusion, ataxia, and urinary incontinence.
Answer choice A: History of personality changes preceding memory changes, is incorrect. This pattern is characteristic of frontotemporal dementia, which presents with brain atrophy in the frontal and temporal lobes on imaging.
Answer choice B: History of stepwise decline in cognitive functioning, is incorrect. This pattern is characteristic of vascular dementia. While this patient has multiple risk factors for vascular dementia (advanced age, hypertension, and diabetes), onset of confusion is more likely to occur in acute bursts, rather than gradual decline. Additionally, neuroimaging typically shows signs of stroke.
Answer choice C: Sensitivity to antipsychotics, is incorrect. This is a common component of Lewy body dementia, which is also characterized by visual hallucinations, rapid eye movement (REM) behavior disorder, and spontaneous parkinsonism. This patient lacks these features, and her imaging findings are more characteristic of normal pressure hydrocephalus.
Answer choice E: Visual hallucinations, is incorrect. Visual hallucinations are a common component of Lewy body dementia, which is also characterized by sensitivity to antipsychotics, REM behavior disorder, and spontaneous parkinsonism. This patient lacks these features, and her imaging findings are more characteristic of normal pressure hydrocephalus.
Key Learning Point
Normal pressure hydrocephalus presents with ventriculomegaly disproportionate to cerebral atrophy on imaging, and is characterized by the triad of confusion, ataxia, and urinary incontinence.
