Thursday, October 23, 2014

Dementia or NPH: A Challenge!

It is difficult to decipher the motivation to diagnose dementia with undignified haste by the present government when there is no real "cure" to speak of. The Cockroach Catcher was brought up to aim to diagnose treatable conditions than incurable ones. It is therefore not unreasonable to suspect that there are different motives: from refusing certain treatment such as hip replacement or organ transplants to promoting dementia medications by big pharmas.

In all the hasty announcements including paying GPs a fee for making such a diagnosis, no mention was made of a diagnosis that mimic dementia. 

 © Am Ang Zhang 2014    


Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 

Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
                                
 Adapted from Ching-yuan (1067-1120)


NPH: Normal Pressure Hydrocephalus

Normal pressure hydrocephalus (NPH) is a relatively new neurologic disorder of elderly patients described by Salamon Hakim in Spanish in a thesis in Bogotá, Colombia, in 1964 . It first appeared in the medical literature in English in 1965 in articles by Hakim and Adams  and Adams, Hakim, et al. NPH is characterized by an unusual triad of neurologic symptoms — impaired gait, urinary and/or fecal incontinence, and dementia — and an anatomic abnormality, i.e., enlargement of the cerebral ventricles that can be demonstrated by computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain . Recently, another anatomic abnormality was described in NPH — a decrease in midbrain diameter on MRI  that is restored to normal by ventriculosystemic shunting . Surprisingly, the intracranial pressure of this unique type of hydrocephalus is normal, or nearly so.

The precise pathogenesis of NPH is not known, but it is well-known that despite the absence of increased intracranial pressure, the drainage of cerebrospinal fluid (CSF) regularly induces transient clinical improvement, and ventriculosystemic shunting (VSS) usually results in prolonged remissions . For reasons that are not clear, some “experts” still question the reversibility of NPH — and even its very existence.

The article is about the apparent lack of awareness amongst today's doctors although neurologists thankfully are more aware of it.

The article concludes:

Furthermore, other disorders of elderly people such as Alzheimer’s disease, Parkinson’s disease, and cerebral atrophy may show enlarged ventricles, and demential disorders may be difficult to differentiate from each other. As a patient with NPH who had erroneously been thought by a competent neurologist to have one of these other disorders for almost a decade [14], I know this differential diagnosis is very difficult.

Moreover, the criteria to define cerebral ventriculomegaly precisely are vague and difficult to establish, and enlarged ventricles are surprisingly common. Many neuroradiologists are reluctant to report borderline or even moderate degrees of hydrocephalus because such diagnoses raise complex, medical, and socioeconomic issues and inadvertently may lead to the performance of brain surgery in less than optimal surgical candidates. Although shunt insertion is not complex surgery and has low morbidity and mortality, it is not free of risk.

Finally, we believe strongly that elderly patients with these symptoms and their loved ones should have the right to make an informed decision as to whether they want shunt surgery, whatever the risk. The first author, having experienced end-stage NPH and having been essentially abandoned to his fate, did not feel that there was much to lose by choosing surgery. Happily, his dementia was subtle and his value center intact, which made the decision easy for him. Even though the decision may be more difficult for naive patients, they should be given the opportunity to make it after an unbiased presentation of the risks and benefits.

So please Mr Hunt and Mr Stevens, can we get the doctors to think NPH before Dementia!



1 comment:

John Smith said...

This information is very useful. thanks for sharing.
Personal Health care services