Normal Pressure Hydrocephalus: The Treatable Dementia

A little known condition called Normal Pressure Hydrocephalus (NPH) afflicts one out of every 200 people over the age of 55.   NPH is a condition where excess fluid accumulates in the cavities (called “ventricles”) inside the brain causing some of the same symptoms as dementia, Alzheimer’s or Parkinson’s disease.   In fact, about 10% of all patients identified as having dementia may actually have NPH.

Yes, NPH disguises itself as dementia, leaving people who could be treated and cured in a hopeless state of oblivion.   Too frequently, the condition goes undiagnosed for many years or indefinitely.   Since the symptoms mimic dementia, many primary care physicians and other specialists tend to look no further.   Or label the condition as “old age.”

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Dr. Osborn

Left untreated, NPH causes progressive decline in function.   “If you can identify NPH, it is potentially curable,” says Dr. Osborn, a neurosurgeon at St. Mary's Hospital in West Virginia.   “It is one the few curable forms of dementia, and when diagnosed and treated, patients may be restored to a relatively normal life.”

If you or a family member have difficulty walking, suffer from mild dementia or have bladder problems, you may have NPH.

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Diagnosis: How is NPH diagnosed?

NPH or Hakim-Adams syndrome, as it is sometimes called, cannot be diagnosed with traditional X-ray.   Dr. Osborn first observes the patient clinically.  If he is suspicious of NPH (as the etiology of the patient’s symptoms), he recommends a CAT scan.  Should the ventricles in the brain appear enlarged and filled with fluid, the doctor will either recommend an additional test or propose placement of a shunt a priori.

Treating NPH: How can NPH be treated?

The standard treatment for NPH is through surgical implantation of a shunt system.   Excess cerebrospinal fluid (CSF) in the brain is diverted to another bodily site and allows the brain to recover.  “Shunt surgery, which takes less than an hour, can produce dramatic results,” says Dr. Osborn, who has performed hundreds of shunt procedures.   One of Dr. Osborn’s patients was an 85-year-old woman with chronic back problems.   She could only walk with the aid of a walker despite multiple low back surgeries.   Physical examination revealed a “magnetic” gait, mild dementia and urinary incontinence.   A CAT scan of the brains showed hydrocephalus (excess fluid in the cavities of the brain).   A special test known as a “lumbar puncture” eliminated some of the excess fluid and caused a marked improvement in her gait.   A shunt operation was proposed.

“The syndrome is too often overlooked,” stresses Dr. Osborn.   “When we implant the shunt, changes are often observed during the initial twenty-four hours postoperatively,” says Dr. Osborn.  And the advent of programmable shunt valves significantly increases the probability of shunt implantation being a one-time procedure (by reducing the incidence of complications associated with shunt implantation).   These valves have multiple programmable choices for the physician to optimize the pressure setting and control fluid drainage. Further reducing the morbidity of the procedure is the fact that the shunt is placed into the abdominal cavity with the use of a laparoscope (camera).   This minimizes the abdominal incisions and results in less postoperative pain.   Also the shunt catheter may be placed in a more strategic location which may reduce the incidence of shunt malfunction (blockage), according to Dr.Osborn.

The Triad of NPH

  • Gait ataxia:  the primary symptom of NPH; an imbalanced, wide-based walk or “shuffle.” Patients claim that their feet feel “stuck to the ground.” Classically the gait is characterized as “magnetic.”
  • Urinary incontinence:  an inability to control one’s urine
  • Dementia:  cognitive decline with associated memory loss

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