Normal pressure hydrocephalus: the "grown-up"version of an underrecognized problem (Part 1 of 3)

Before I go any further into my topic, I will ask my reader's to please not take offense at the illustration above. It is a light-hearted way to explain the effects of a condition that affects an estimated 700,000 Americans and often goes undiagnosed and untreated. According to the Hydrocephalus Association, an estimated 80% of cases remain unrecognized by the medical community.

I. What is normal pressure hydrocephalus (NPH)?

Many people aren't family with the term Hydrocephalus but, if you refer to it as "water on the brain" they immediately know what you are referring to. In older adults it manifests itself as Normal pressure hydrocephalus or NPH. The term "water" is a misnomer, however, because the substance that creates the problem is cerebrospinal fluid (CSF). As the CSF builds up, it can cause dangerously high intracranial pressure (ICP) and affect how the brain functions. There are a number of factors that can cause NPH including: head injury, surgery, or a brain bleed (hemorrhage).

II. What are the symptoms of NPH?

The term Normal pressure hydrocephalus was first coined by Dr. Salomon Hakim (pictured at right) in his 1964 paper which spoke of a type of hydrocephalus where there is little or no increase in the ICP and occurred primarily in older adults. One thing that made NPH so dramatically different from other forms of hydrocephalus was what Dr. Hakim referred to as the triad of symptoms. These are: 

Gait disturbances which can range from a mild imbalance to a total inability to stand or walk at all. Often described as a "magnetic gait" characterized by wide-based, short steps with a noticeable shuffle. Additionally, persons with NPH might have problems picking up their feet making the navigation of curbs and stairs difficult and placing them at a higher risk for falls.

Mild dementia can be described as the loss of interest in activities, becoming forgetful, difficulty performing daily routine tasks, and short-term memory loss. Typically these symptoms are less severe than those seen with full-blown dementia and are often overlooked for years or dismissed as a consequence of aging. Persons with NPH usually do not  (emphasis added) lose language skill, but their deficits might not be as obvious to them and they might deny there is even a problem.

Impairment of bladder control is usually characterized by both urinary frequency and urgency, however, the complete loss of bladder control (urinary incontinence) can occur in more severe cases. As a point of education, urinary frequency is a need to urinate more frequently -- sometimes as much as every one to two hours. Urinary urgency is the strong, immediate sensation of the next to urinate. In some cases, this urge is so strong that it cannot be held back resulting in incontinence. In very rare cases, fecal incontinence can also occur.

For additional information: Hydrocephalus facts and stats, NPH article NPH booklet