Personal history

Abstract

There is nothing particularly compelling about a 78-year-old man with a gait disturbance and occasional loss of bladder control. The question I needed to address was: Did he also have cognitive decline? Our department has devoted considerable attention to “the special clinical problem of symptomatic hydrocephalus with normal CSF pressure.” We developed a cognitive and gait assessment battery to predict responsiveness to ventriculoperitoneal shunt. Typically, I am the one who performs these evaluations. The patient was an elderly Jewish man with a slowly progressive 4-month history of difficulty in gait initiation and urinary incontinence. His family members also reported he seemed less interested in his surroundings and showed less initiative, but they weren’t certain he had any actual memory impairment or other clear evidence of cognitive decline. Perhaps he was just depressed. In accepting the referral, I could not know how much more profound this patient’s impact would be on us than ours would be on him. Thursday is grand rounds day in our department and always hectic in the extreme. There is much to be done prior to grand rounds, of course, but also in anticipation of the upcoming weekend, for Friday is a short workday in Israel prior to the beginning of the Sabbath at sundown. When I arrived early that morning, the patient I found was not the patient I had been “sold” the previous afternoon: Though seemingly alert and attentive, he was almost completely unable to respond to simple questions. He was having some difficulty eating the breakfast his son was attempting to feed him. His son reported he had noticed the change in his father’s condition about 2 hours earlier and had remarked …