Normal pressure hydrocephalus and reversible dementias — structured clinical viva · Psych Vivas

Prompt

You are the psychiatry registrar on CL. A 74-year-old woman was admitted with failure to thrive and 'depression'. She has a 3-year magnetic gait, urinary urgency, apathy, and executive slowing. Family were told she has Alzheimer disease. MRI is described as showing DESH-type ventriculomegaly. Discuss definition and Relkin criteria, neuropsychiatric profile, differentials, reversible-dementia epidemiology (Clarfield/Hejl), work-up including CSF tap test, shunt evidence (SINPHONI-2, Toma), counselling points, and capacity for surgical consent.

Viva structure

Opening definition

Expected points

Define NPH as symptomatic communicating hydrocephalus with normal-range CSF pressure and the Hakim–Adams triad (gait, cognition, urinary), citing 1965 descriptions. Distinguish idiopathic vs secondary NPH.[1][8]

Criteria and imaging

Expected points

Relkin probable/possible/unlikely categories; gait mandatory for probable; DESH and Japanese guideline operationalisation; Evans index as rough ventriculomegaly flag only.[2][3]

Neuropsychiatry

Expected points

Apathy is the commonest NPI symptom (Kito); depression and anxiety frequent; CL mislabel as primary depression common.[7]

Reversible dementia literacy

Expected points

Clarfield: potentially reversible ~9%, actually reversed ~0.6%. Hejl: higher potentially reversible rates in memory-clinic consecutive series. Treat co-factors without promising universal cure.[4][10]

Pathway and evidence

Expected points

Optimise medical factors → MRI phenotype → CSF tap test/ELD → counsel → shunt (VP/LP; SINPHONI-2 for LP shunt RCT). Toma review: improvement common in selected modern series; complications real. Gait most responsive domain.[5][6][8]

Capacity and safety

Expected points

Decision-specific capacity for surgery (Appelbaum). Falls, driving, carer burden, advance planning. Local guardianship statutes named as jurisdiction-specific without inventing section numbers.[9][8]

References

[1]Adams RD, Fisher CM, Hakim S, et al. SYMPTOMATIC OCCULT HYDROCEPHALUS WITH NORMAL CEREBROSPINAL-FLUID PRESSURE. A TREATABLE SYNDROME N Engl J Med, 1965.PMID 14303656
[2]Relkin N, Marmarou A, Klinge P, et al. Diagnosing idiopathic normal-pressure hydrocephalus Neurosurgery, 2005.PMID 16160425
[3]Nakajima M, Yamada S, Miyajima M, et al. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus Neurol Med Chir (Tokyo), 2021.PMID 33455998
[4]Clarfield AM The decreasing prevalence of reversible dementias: an updated meta-analysis Arch Intern Med, 2003.PMID 14557220
[5]Kazui H, Miyajima M, Mori E, et al. Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial Lancet Neurol, 2015.PMID 25934242
[6]Toma AK, Papadopoulos MC, Stapleton S, et al. Systematic review of the outcome of shunt surgery in idiopathic normal-pressure hydrocephalus Acta Neurochir (Wien), 2013.PMID 23975646
[7]Kito Y, Kazui H, Kubo Y, et al. Neuropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus Behav Neurol, 2009.PMID 19996513
[8]Williams MA, Malm J Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus Continuum (Minneap Minn), 2016.PMID 27042909
[9]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
[10]Hejl A, Høgh P, Waldemar G Potentially reversible conditions in 1000 consecutive memory clinic patients J Neurol Neurosurg Psychiatry, 2002.PMID 12235305

Viva structure

Opening definition

Expected points

Criteria and imaging

Expected points

Relkin probable/possible/unlikely categories; gait mandatory for probable; DESH and Japanese guideline operationalisation; Evans index as rough ventriculomegaly flag only.[2][3]

Neuropsychiatry

Expected points

Apathy is the commonest NPI symptom (Kito); depression and anxiety frequent; CL mislabel as primary depression common.[7]

Reversible dementia literacy

Expected points

Pathway and evidence

Expected points

Capacity and safety

Expected points

Decision-specific capacity for surgery (Appelbaum). Falls, driving, carer burden, advance planning. Local guardianship statutes named as jurisdiction-specific without inventing section numbers.[9][8]

References

[1]Adams RD, Fisher CM, Hakim S, et al. SYMPTOMATIC OCCULT HYDROCEPHALUS WITH NORMAL CEREBROSPINAL-FLUID PRESSURE. A TREATABLE SYNDROME N Engl J Med, 1965.PMID 14303656
[2]Relkin N, Marmarou A, Klinge P, et al. Diagnosing idiopathic normal-pressure hydrocephalus Neurosurgery, 2005.PMID 16160425
[3]Nakajima M, Yamada S, Miyajima M, et al. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus Neurol Med Chir (Tokyo), 2021.PMID 33455998
[4]Clarfield AM The decreasing prevalence of reversible dementias: an updated meta-analysis Arch Intern Med, 2003.PMID 14557220
[5]Kazui H, Miyajima M, Mori E, et al. Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial Lancet Neurol, 2015.PMID 25934242
[6]Toma AK, Papadopoulos MC, Stapleton S, et al. Systematic review of the outcome of shunt surgery in idiopathic normal-pressure hydrocephalus Acta Neurochir (Wien), 2013.PMID 23975646
[7]Kito Y, Kazui H, Kubo Y, et al. Neuropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus Behav Neurol, 2009.PMID 19996513
[8]Williams MA, Malm J Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus Continuum (Minneap Minn), 2016.PMID 27042909
[9]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
[10]Hejl A, Høgh P, Waldemar G Potentially reversible conditions in 1000 consecutive memory clinic patients J Neurol Neurosurg Psychiatry, 2002.PMID 12235305