Management of Elderly Female Patient with Normal Pressure Hydrocephalus and Acute Mountain Sickness
For an elderly female patient with Normal Pressure Hydrocephalus (NPH) and Acute Mountain Sickness (AMS), immediate descent from altitude (minimum 300m) is the primary treatment, along with neuroimaging to evaluate the NPH component and appropriate medical management for both conditions.
Initial Assessment and Management of AMS
Immediate Interventions for AMS
- Immediate descent from altitude (minimum 300m) is the primary treatment for AMS 1
- Administer supplemental oxygen if available to maintain SpO₂ >90% 1
- For cerebral symptoms, dexamethasone should be administered 1
- If descent is impossible or delayed, consider nifedipine 1
Risk Factors and Considerations for Elderly Females with AMS
- Women may have a higher risk of AMS than men 2, 1
- Elderly patients may experience more severe symptoms due to decreased physiological reserve
- Menopause results in gradual loss of estrogen, which may affect responses to hypoxia 2
- Women may experience initially more pronounced reduction in oxygen saturation following hypoxia exposure, potentially resulting in elevated pulmonary vascular resistance 2
Evaluation and Management of NPH
Neuroimaging
- CT head without contrast is the first-line imaging test for evaluating altered mental status in elderly patients 2
- MRI brain is complementary to CT and should be performed to evaluate for hydrocephalus and other intracranial pathologies 2
- Ventriculomegaly (not due to cerebral atrophy) and transependymal edema are hallmarks of acute hydrocephalus 2
Assessment of Intracranial Pressure (ICP)
- Measure opening pressure during lumbar puncture
- Pressures of 180–250 mm H2O are concerning but don't require specific intervention 2
- Pressures ≥250 mm H2O define the need for urgent intervention 2
- For increased ICP, remove CSF to reduce pressure to 50% of opening pressure or 200 mm H2O, whichever is greater 2
NPH Management
- Consider neurosurgical consultation for possible shunt placement 3
- Monitor for symptoms of hydrocephalus: headache, altered mental status, gait abnormality, urinary incontinence, and nausea/vomiting 2
- CSF parameters are important variables in monitoring treatment success 2
Integrated Management Approach
Step 1: Address AMS First
- Immediate descent from altitude (minimum 300m) 1, 4
- Administer supplemental oxygen to maintain SpO₂ >90% 1
- Consider dexamethasone for cerebral symptoms 1
Step 2: Evaluate NPH Component
- Perform neuroimaging (CT head without contrast initially, followed by MRI) 2
- Assess for ventriculomegaly and transependymal edema 2
- Perform lumbar puncture to measure opening pressure and evaluate CSF parameters 2
Step 3: Ongoing Management
- Monitor for improvement in AMS symptoms after descent
- Consider acetazolamide for persistent AMS symptoms 1
- For NPH, consider neurosurgical consultation for possible shunt placement 3
- Monitor for clinical improvement in the NPH triad (gait disturbance, urinary incontinence, cognitive decline)
Common Pitfalls and Caveats
- Do not delay descent in a patient with AMS, as it can progress to high-altitude cerebral edema (HACE), which has 50% mortality when untreated 5
- Avoid attributing all symptoms to AMS without proper evaluation of NPH
- Do not assume NPH symptoms will resolve with AMS treatment alone
- Be aware that symptoms of hydrocephalus may overlap with those of AMS, creating diagnostic confusion 2
- Recognize that ventricular fluid pressure may be normal in some cases of hydrocephalus, so this finding alone should not exclude the diagnosis 2
- Elderly patients with NPH often have risk factors for ischemic cerebrovascular disease and may have multiple small ischemic lesions 3
By following this approach, clinicians can effectively manage both the acute condition (AMS) and the chronic condition (NPH) in elderly female patients, prioritizing interventions that will most significantly impact morbidity, mortality, and quality of life.