NPH If a patient has hydrocephalus plus the triad of urinary changes, cognitive changes, and gait changes, suspect NPH. NPH diagnosis is based on clinical symptoms as well as transient improvement of symptoms after CSF drainage. Shunt surgery is the only established treatment for NPH. Before doing so, though, rule out reversible causes of these symptoms. NPH Triad Urinary Symptoms Urinary urgency
Urinary frequency
Incontinence
Duration of urinary symptoms Days
Weeks
Months
Years
Gait Symptoms Slowness/Unsteadiness with walking or initiating movements
Feet feel stuck to the ground
Wide base, small steps, difficult to turn
Need for walking aide (what type and for what duration)
Falls (frequency and severity)
Duration of gait symptoms Days
Weeks
Months
Years
Cognitive Symptoms Characterize Symptoms Slowed thinking
Difficulty initiating thoughts
Decreased attention/concentration
Difficulty following directions or multi-tasking
Apathy
Duration of cognitive symptoms Days
Weeks
Months
Years
Baseline cognitive status Highest level of education attained None
Elementary School
Middle School
Some High School
Graduated High School
Some college
Graduated college
Masters or higher
History of childhood learning difficulties
Currently employed
Difficulties with work performance
Baseline functional status Able to perform ADLs
Able to perform IADLs
Currently driving
Screen for other causes of Hydrocephalus Large head circumference (Decompensated congenital hydrocephalus)
Active malignancy (leptomeningeal mets causing obstructive hydrocephalus)
Immunosuppressed (CNS infection causing obstructive hydrocephalus)
Screen for other causes of Memory Impairment TSH
Vitamin Deficiencies
HIV
Syphilis
OSA screen
Depression and anxiety screen
Tobacco, drug, alcohol use (current and remote)
Vascular risk factors, history of stroke (vascular dementia)
Family history of neurologic or psychiatric conditions
History of SAH/ICH/SDH, severe TBI, meningitis/encephalitis, brain surgery, or whole brain radiation (secondary causes of NPH)
Screen for other causes of Gait Impairment Prior neck or back surgery (cervical/lumbar stenosis)
Hip and knee arthritis
Peripheral neuropathy
Peripheral vestibular dysfunction (h/o BPPV or vestibular neuritis)
History of alcohol abuse
Postural hypotension
Presence of rest tremor and/or rigidity (Parkinsons)
Previous Workup Prior brain or spine imaging
Vascular risk factor assessment (LDL, A1c, CTA)
Prior high volume LP
Prior gait assessment
Prior PT/OT assessment
Prior speech therapy (cognitive assessment)
Bedside cognitive testing (MOCA, SAGE, MMSE)
Formal neuro-psychologic testing