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Your Good Health: Some less-frequent forms of dementia are treatable

Normal pressure hydrocephalus is not always recognized in seniors with dementia and an NPH diagnosis and shunt insertion can stop symptoms.
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Dr. Keith Roach

Dear Dr. Roach: Could you address the issues that come with the diagnosis of normal pressure hydrocephalus? My 82-year-old husband was diagnosed with NPH after experiencing a slow decline in walking and some cognitive decline.

An MRI showed moderately enlarged ventricles, and a lumbar puncture test was done, which gave him about 24 hours of normal walking. He is now five days post-op from a shunt insertion.

It seems that NPH is not always recognized in some seniors who are demonstrating signs of dementia, and an NPH diagnosis and shunt insertion can even stop symptoms of dementia.

S.P.

Dementia is a slow decline in several areas of brain function. Many people jump to the most common diagnosis of Alzheimer’s when they see signs of dementia in their loved ones, but physicians need to be on the alert for the less-frequent, treatable types of dementia.

You’ve identified two of the critical, presenting features of NPH: dementia and a change in walking. The gait usually consists of small and slow steps, with difficulty turning (and the person may fall, especially while turning). Features of dementia include overall slowing of thought, decreased concentration and apathy — so that they may appear depressed. The third characteristic, urinary incontinence, does not always occur, but when it does, it starts as an urgency to get to the bathroom right away (which they might not be able to do, especially given the slow gait). It progresses to apathy about incontinence.

As you said, a shunt (a tube that drains the excess fluid from the brain to the abdomen, to relieve dangerous fluid buildup in the brain) is an effective treatment. If a trial of relieving pressure by removing fluid from the brain is effective at improving symptoms, a shunt is then placed.

You are absolutely right that the condition may not be recognized, or misdiagnosed, so I appreciate your writing to make more people aware of this condition and, hopefully, get some people treated.

Dear Dr. Roach: A recent letter in your column about back and hip pain sounded similar to my situation. For the last year, I have received three shots — two in the spinal area and one in the hip area. I will probably have hip surgery in the fall, God willing. But I recently read that these shots, Xylocaine and Kenalog, can do harm to bone mass and that I am better off with Tylenol. Are either of these the kind of medicine that affects bone mass?

J.S.

Xylocaine is a brand of lidocaine, a common topical anesthetic agent. It is injected into joint spaces and other areas to numb pain. It also helps a clinician know that they are in the right spot when they simultaneously inject a corticosteroid like triamcinolone (Kenalog), a powerful anti-inflammatory that is effective at relieving pain due to inflammation.

All medicines have the potential for harm, and although steroids taken daily are a major risk factor for osteoporosis (low bone mass), three shots a year of Kenalog are unlikely to significantly reduce bone density. Many experts use them to help relieve pain while waiting for a definitive treatment such as joint replacement.

Very frequent steroid injections may cause problems with elevated blood sugar levels and damage to cartilage, so these aren’t used indefinitely, except when there aren’t any other good options (such as a person who cannot tolerate surgery).

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu