Normal Pressure Hydrocephalus: The Only Reversible Form of Dementia

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“I started to feel like I was walking on gum, like I could not lift and place my feet properly – I was shuffling along. Over time, I required a walker, then a wheelchair. I started having problems with balance, fatigue, incontinence, increased irritability and a noticeable decline in my ability to think and process information.” said Gilda Katz

This is what it is like to experience the onset of Normal Pressure Hydrocephalus (NPH), widely described as the only reversible form of dementia by medical professionals. Affecting more than one in 200 adults aged 55 and older, NPH is difficult to diagnose and frequently misdiagnosed as Alzheimer’s or Parkinson’s disease. Once diagnosed, however, the condition is readily treatable and the symptoms can often be reversed. This neurological disorder is characterized by an excessive accumulation of cerebral spinal fluid (CSF) in the ventricles of the brain, sometimes with little or no increase in intracranial pressure. The cause is unknown in most cases and NPH is not an inherited or genetic condition.

What Are the Symptoms?
The classic symptoms of NPH, gait disturbances, mild dementia and impaired bladder control, as described below, are not always present at the same time and typically develop gradually over months or years.

Gait Disturbances (Difficulty Walking)
Usually the most pronounced and first to appear, gait disturbances range from mild imbalance and instability to inability to stand or walk. A person’s gait may be wide-based, short-stepped, slow and shuffling. Individuals have trouble picking up their feet and often trip over curbs and fall. They describe the feeling as “feet stuck to the floor.” Turning around requires many small steps.

Mild Dementia
This is a loss of interest in daily activities, forgetfulness, difficulty performing routine tasks and short-term memory loss. Cognitive symptoms are often overlooked for years or accepted as a consequence of aging. Not everyone will have obvious cognitive impairment; conversational skills and thinking abilities may be unchanged. Cognitive changes may be detectable only with formal neuropsychological testing.

Impaired Bladder Control
This can range from urinary frequency and urgency in mild cases to complete loss of bladder control in severe cases, when urinary urgency is strong and cannot be controlled. Not all individuals with NPH display signs of bladder problems.

Diagnosis & Treatment
An early diagnosis is believed to increase the chances of successful treatment. Once a physician suspects NPH, testing is usually conducted to confirm the diagnosis and assess suitability for treatment. Surgical implantation of a shunt to drain CSF from the brain to another part of the body is the most common and usually the only available treatment for NPH. It is important that a neurosurgeon or neurologist becomes part of the medical team to interpret test results and discuss surgery and its risks. Symptoms will be evaluated with physical and neurological examinations, including:
•Discussion and observation of walking and turning for gait disturbance;
•Asking questions/administering neuropsychological evaluations for cognition;
•Verbal assessment of urinary urgency and frequency or incontinence;
•An MRI or CT scan to detect enlarged ventricles;
•Possibly CSF tests such as lumbar puncture (spinal tap).

Shunt Surgery
No single factor is reliable in predicting success from shunt implantation. The chance of a more complete recovery depends on several factors. It is important to discuss the expected outcomes for regaining motor skills or mental ability with your medical team. Although NPH is a chronic condition, with early detection, effective treatment and appropriate intervention services, symptom reversal and a return to a high quality of life is increasingly possible. The future for individuals with NPH is promising.

“…The doctor took me out in the hall. With a twinkle in his eye, he pointed to my husband at the end of the corridor and told me to,‘Walk over to your husband and give him a kiss.’ ‘Walk without a walker?’ I thought, ‘I can’t.’ But I could, and I DID!” said Gilda Katz.

For more information, including details about NPH support groups, visit the Spina Bifida & Hydrocephalus Association of Ontario (SB&H) website at http://www.sbhao.on.ca