“Dad’s gone unsteady and forgetful and he’s started wetting himself — the family say it’s just dementia”

The combination of GAIT disturbance + COGNITIVE impairment + URINARY incontinence — the classic triad of NORMAL-PRESSURE HYDROCEPHALUS (NPH) (best not described to families with informal mnemonics) — is a POTENTIALLY REVERSIBLE cause of a dementia-like syndrome that must NOT be dismissed as "just dementia/old age", because CSF diversion (shunting) can improve symptoms (especially gait) in selected patients, and missing it loses a reversible opportunity. Crucially, the GAIT disturbance is typically the EARLIEST and most prominent feature — a broad-based, shuffling, slow, "magnetic"/feet-stuck gait with unsteadiness and falls — so a gait-led decline accompanied by incontinence and cognitive change should raise NPH rather than be attributed to Alzheimer’s or ageing. Still perform a thorough REVERSIBLE-CAUSE work-up for the same picture: medication review (sedatives/anticholinergics), bloods (NICE NG97: FBC, ESR or CRP, U&E, calcium, HbA1c/glucose, LFTs, TFTs, B12/folate), depression (pseudodementia), Parkinson’s/parkinsonism, cerebrovascular disease, and delirium (e.g. UTI causing confusion/incontinence), prostatic overflow or chronic retention (NICE CG97) and a subdural haematoma after falls, with a face-to-face cognitive assessment, lying and standing blood pressure and examination, as video cannot provide these (NICE NG97, NICE NG249). Refer for NEUROLOGY/specialist assessment and BRAIN IMAGING (CT/MRI showing ventricular enlargement out of proportion to cortical atrophy), with specialist assessment (including CSF tap-test response) determining shunt suitability. Support the distressed family/carer — counter the "just old age / is there any point?" nihilism with the possibility of a reversible cause while managing expectations realistically (not all NPH improves; coexisting pathology is possible), arrange interim falls and continence support, address carer needs, and engage the patient with dignity rather than only the relative, asking his permission before discussing him with his son (Mental Capacity Act 2005) and offering the son a carer’s assessment (Care Act 2014). The hidden agenda is therapeutic nihilism; recognise the triad, investigate, refer, and support — not accept "just dementia".