Case 29 – A Man with Urinary Incontinence and Trouble Walking

Abstract

A 71-year-old man was admitted for gradually difficult walking for 3 years along with memory impairment and urinary incontinence for 1 year. At first, this patient just complained of weakness while walking and dizziness. He was treated for arterial hypertension; however, no relief was obtained. He experienced more difficulties in walking and initiating steps. Besides these symptoms, his memory and thinking ability declined. His wife found that he responded slowly with personality change from a talkative and considerative gentleman to a silent man with apathy. The patient often felt urinary urgency, sometimes with incontinence. It was considered as symptoms of prostate hypertrophy. He was referred to a neurologist and MRI reported some lacunar infarctions and brain atrophy (retrospectively, lateral ventricles enlargement already existed). His Mini-Mental State Examination (MMSE) score was 18 points. Lumbar puncture (LP) was performed and cerebrospinal fluid (CSF) results were normal. The patient was diagnosed as having vascular dementia, hypertension and treated with neuroprotective agents and antihypertensives. After hospitalization, his symptoms were temporarily and partially relieved. His MMSE score was improved to 24 points when he was discharged.

Case 29 A Man with Urinary Incontinence and Trouble Walking

Linyan Tong , Kok Pin Ng , Yuxue Feng , Yu Li , Zongyi Xie , and Xiaofeng Li

29.1 Case History

Afterward, the patient still had symptoms as above. Two years later, the patient was referred to a neurosurgeon. Recognition and short-term memory had declined and head CT showed hydrocephalus with lacunar infarctions. LP was performed again. Intracranial pressure was 100 mm H₂O; however, a formal assessment of gait after the CSF tap was not performed.

Six years after the onset of symptoms the patient’s symptoms further worsened. He could only slowly move on a smooth surface with the support of walking stick, although the muscle strength of his legs was normal. He lost the ability to communicate and could not attend social gatherings. He began to use diapers because of frequent urinary incontinence. A ventriculoperitoneal shunt was performed. One year after surgery the head CT showed hydrocephalus with no obvious change compared with last time. In the next 2 years of irregular follow-ups, the patient’s condition was stable. His wife felt the patient appeared a little bit better after adjusting the pressure of the shunt. During the year before the last follow-up, the patient had small cerebral hemorrhages twice, in the pons and the left thalamus, respectively. At the last visit, the patient was conscious, could move in a wheel-chair and walk several steps with support, could answer his own name in a low voice and shake hands with visitors, wearing diapers, MMSE score was 4 points.

29.2 Discussion

Idiopathic normal pressure hydrocephalus (iNPH) was first described by Hakim and Adams in 1965, with a typical clinical triad of gait disturbance, cognitive impairment, and urinary incontinence in elderly patients, associated with enlargement of the cerebral ventricular system and good response to shunt surgery.¹ iNPH is an age-related disorder and its prevalence increases with age. In a community-based elderly population epidemiology study prevalence was about 1.4% in elderly adults. In a large elderly population in Sweden, the prevalence of probable iNPH was 0.2% in those aged 70–79 years and 5.9% in those aged 80 years and older. However, due to the subtle clinical onset and nonspecific nature of the clinical symptoms, the early diagnosis for iNPH is often challenging.

In this case, the patient was not diagnosed appropriately until 3 years later. Though the triad of gait disturbance, cognitive impairment, and urinary incontinence were present, each symptom was attributed to other diseases instead of iNPH. At first, dizziness was explained as the result of hypertension and the cognitive impairment was ignored and later interpreted as vascular dementia. Gait disturbance was misunderstood as fatigue and weakness of legs, even though the strength of the legs was confirmed to be normal. Urinary incontinence was noticed; however, it was explained as the result of prostate hypertrophy. Therefore understanding the clinical manifestation of iNPH is important.

29.2.1 Gait Disturbance

Gait disturbance is most likely the earliest and the most frequent symptom or sign that can be noticed. In the early course of the disease, the gait disturbance may be subtle and indistinguishable from careful senile gait. Patients may describe themselves as feeling dizzy or unstable as in this case. Later on, gait becomes evidently unstable and it may adopt a shuffling appearance similar to parkinsonian gait disorders. Patients then may complain of leg weakness, although formal neurologic assessment usually does not show motor deficits. iNPH gait is characterized by diminished gait velocity, mostly due to a diminished stride length, reduced step height, decreased foot-to-floor clearance, slow movement of the lower extremities, and a prominent disturbance of dynamic equilibrium, which was clearly distinguishable from the gait of patients with Parkinson’s disease. The number of steps may be increased on turning. Findings include difficulty with movements; gait initiation failure; falling or festination; unstable multistep turns. The unique gait disturbance of iNPH with further progression of the disease are described as magnetic gait or as walking as if the feet were glued to the floor.²

29.2.2 Cognitive Impairment

Cognitive deficits are almost always present; however, they may also be subtle and even unrecognized in the early phase of the disease and may be detected only by neuropsychological examination. Patients with iNPH exhibit subcortical-type mental deficits that differ from that of Alzheimer’s disease (AD). Common features include mental and motor slowing, apathy, emotional indifference, anosognosia, impaired memory and attention, decreased speed of information-processing and impaired executive function, including difficulty managing finances, taking medications properly, driving, and keeping track of appointments.²

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