You’re on geriatrics
Your shift should have ended an hour ago.
But unfortunately, you're the sucker too honest to lie about your imaginary kids' dance recital.
(The NHS salutes your integrity. Your co-workers are cosy, watching Love is Blind or reading the best medical newsletter the world)
Now it’s just you and a ward of elderly folk, with different elderly problems. Let’s do a quick roll-call:
Dani has dementia. Fawn keeps falling. Ilona is incontinent.
Norman has all three. He’s wet, wobbly and wacky.
Textbook normal-pressure hydrocephalus.
No problem. Just have a chat with neurosurgery, put a shunt in and voila – Norman’s normal again...Right?
Well, no. Of course not.
The problem is that shunting is kinda like the “keto diet” of neurosurgery: small evidence base, strong placebo effects and questionable long-term gains. The literature’s been begging for more studies to be done to see if shunting is actually worth the hassle.
Their prayers were answered.
Published in , the aim of this trial was to figure out if shunt surgery actually improves symptoms in patients with idiopathic normal pressure hydrocephalus(iNPH).
This multicentre RCT recruited 99 participants. They were included if they had iNPH, if they could walk 10 meters unaided and could walk a speed of 1.0m/sec or more.
They coin-flipped patients into one of two groups:
Open shunt group (49 patients): The shunt valve is set to an opening pressure of 110mm of water.
Placebo group (50 participants): The shunt valve was set to an opening pressure of over 400mm of water. A pressure so high nothing was getting drained.
3 months after the surgery, all three cardinal symptoms were measured: Gait velocity was the primary outcome measure. Cognition and continence were secondary, measured using MoCA and the Overactive Bladder Questionnaire respectively.
Wobbly: In the treatment group gait velocity improved by 0.23 m/sec. This contrasts the placebo which did nish (0.03 m/sec improvement). This net shunting a sweet and significant 0.21 m/sec improvement over placebo (95% CI, 0.12–0.31; P=0.001).
Wet: There was no significant difference in the Overactive Bladder Questionnaire.
Wacky: There was no significant difference in the MoCA score either.
So whilst Norman may be steadier on his feet, he’ll still soak the bed and confuse the consultant for his late wife, Margaret(Mr Gravenberch is a bit androgynous looking tbf).
Perhaps if the trial didn’t exclude those who couldn’t 10 meters alone, those on long-term anticoagulants(most over 70) those recorded over a longer time horizon the findings might have been different.
Regardless, when iNPH is involved, shunt ahead…
because that’s the only treatment we got.
