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Normal Pressure Hydrocephalus — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryNormal Pressure HydrocephalusMRCPsych Paper B

A 72-year-old man has developed progressive difficulty walking over 18 months. He now takes short, broad-based steps, has difficulty initiating gait and is unsteady when turning. His family report slowed thinking and reduced initiative, and he has developed urinary urgency with occasional incontinence. There are no focal neurological deficits. Brain imaging shows ventricular enlargement disproportionate to the degree of cortical atrophy. Which condition is most likely?

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Correct answer: E — Normal pressure hydrocephalus

The correct answer is **C, normal pressure hydrocephalus**. The discriminating features are a gait-first syndrome with impaired initiation and turning, frontal-subcortical cognitive slowing, urinary dysfunction and ventriculomegaly disproportionate to cortical atrophy. NPH is important because appropriately selected patients may improve following CSF shunting. Alzheimer's disease usually begins with prominent episodic-memory impairment, while gait disturbance and incontinence tend to occur later and imaging more typically shows cortical or medial temporal atrophy. Vascular dementia is suggested by a stepwise course, focal deficits or cerebrovascular lesions. Frontotemporal dementia more often presents earlier with behavioural or language change. Creutzfeldt-Jakob disease progresses rapidly over weeks or months and commonly produces neurological features such as myoclonus, ataxia or pyramidal signs.

Reference: National Institute for Health and Care Excellence. Lumbar infusion test for the investigation of normal pressure hydrocephalus, HTG169, section 2: The procedure. 2008. https://www.nice.org.uk/guidance/HTG169/chapter/2-the-procedure