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ABSTRACT: Gait instability, urinary incontinence, and dementia are the signs and symptoms typically found in patients who have normal pressure hydrocephalus. Estimated to cause no more than 5 percent of cases of dementia, normal pressure hydrocephalus often is treatable, and accurate recognition of the clinical triad coupled with radiographic evidence most commonly identifies likely responders. Magnetic resonance imaging or computed tomography typically demonstrates ventricular dilation with preservation of the surrounding brain tissue. The abnormality in normal pressure hydrocephalus occurs secondary to an abnormality in fluid removal, leading to an increase in ventricular size and encroachment of enlarged ventricles on adjacent brain tissue. The pressure exerted on the cerebral parenchyma by immense fluid-filled cavities deforms white matter tracts, instigating gait abnormalities and incomplete control of the bladder, as well as difficulties in processing incoming stimulation and in producing expeditious responses. Signs and symptoms often occur as sequelae to an imbalance between the expected ongoing production of cerebrospinal fluid and continuous efflux. Ventriculoperitoneal shunting is used to relieve excess ventricular fluid not absorbed by normal physiologic channels. Multiple studies have explored various techniques to identify patients with normal pressure hydrocephalus in an effort to predict likely benefit from shunting. However, the effectiveness of cerebrospinal fluid diversion has never been proven in a randomized controlled trial comparing use of a shunt versus no shunt.
ABSTRACT: Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.
American Heart Association Issues Guidelines on Imaging in Transient Ischemic Attacks and Stroke - Special Medical Reports
Alcoholism in the Elderly - Article
ABSTRACT: Alcohol abuse and alcoholism are common but underrecognized problems among older adults. One third of older alcoholic persons develop a problem with alcohol in later life, while the other two thirds grow older with the medical and psychosocial sequelae of early-onset alcoholism. The common definitions of alcohol abuse and dependence may not apply as readily to older persons who have retired or have few social contacts. Screening instruments can be used by family physicians to identify older patients who have problems related to alcohol. The effects of alcohol may be increased in elderly patients because of pharmacologic changes associated with aging. Interactions between alcohol and drugs, prescription and over-the-counter, may also be more serious in elderly persons. Physiologic changes related to aging can alter the presentation of medical complications of alcoholism. Management of alcohol withdrawal in elderly persons should be closely supervised by a health care professional. Alcohol treatment programs with an elder-specific focus may improve outcomes in some patients.
Evaluation of First Nonfebrile Seizures - Article
ABSTRACT: Nonfebrile seizures may indicate underlying disease or epilepsy. The patient history can often distinguish epileptic seizures from nonepileptic disorders by identifying the events directly preceding the convulsion, associated conditions, and details of the seizure, including triggers, length, and type of movements. Laboratory testing, lumbar puncture, and neuroimaging may be indicated depending on the presentation, suspected etiology, and patient’s age. Electroencephalography should be performed 24 to 48 hours after a first seizure because of its substantial yield and ability to predict recurrence. Neuroimaging is recommended for adults, infants, and children who have cognitive or motor developmental delay or a focal seizure. Neuroimaging may be scheduled on an outpatient basis for patients with stable vital signs who are awake and have returned to neurologic baseline. Emergent neuroimaging should be performed in patients with persistent decreased mental status or a new focal neurologic abnormality. Although magnetic resonance imaging is generally preferred to head computed tomography because of its greater sensitivity for intracranial pathology, computed tomography should be performed if intracranial bleeding is suspected because of recent head trauma, coagulopathy, or severe headache. Treatment with an antiepileptic drug after a first seizure does not prevent epilepsy in the long term, but it decreases the short-term likelihood of a second seizure. Adults with an unremarkable neurologic examination, no comorbidities, and no known structural brain disease who have returned to neurologic baseline do not need to be started on antiepileptic therapy. Treatment decisions should weigh the benefit of decreased short-term risk of recurrence against the potential adverse effects of antiepileptic drugs.