The NPH Puzzle

Diagnosing normal pressure hydrocephalus is a challenge because the three hallmark symptoms are found individually in other conditions. Furthermore, not all patients present with all three symptoms of the NPH puzzle even when they may have NPH. Nevertheless, any or all of the following three symptoms, combined with brain scans, lumbar puncture or brain catheter, will indicate the correct diagnosis:   

The NPH Puzzle at Georgia Regents

Walking Difficulties

Mild Dementia

Poor Bladder Control

Difficulty walking is usually the first symptom to appear and is usually the most pronounced. The person's walking stride becomes more wide-based and slow, with a shuffling-type gait. Balance can be impaired and frequent falls may occur. The person may have difficulty turning corners or lifting their feet.

The mild dementia associated with NPH is often mistaken as a typical consequence of aging. The symptoms can include forgetfulness, loss of interest in daily activities and reduced organizational and problem-solving skills. The dementia associated with NPH is usually less severe than dementia associated with other conditions such as Alzheimer's.

Poor bladder control may range from urinary frequency to incontinence. In the early stages of NPH, the need to urinate frequently, or the urgent need to urinate are most prevalent. Later stages of NPH may be characterized by total loss of bladder control, or incontinence. However, some people with NPH never have bladder control problems.