Does Normal Pressure Hydrocephalus Cause Dementia

Ask The Expert Video Series On Nph

Dr. Mark Luciano, neurosurgeon, and Dr. Abhay Moghekar, neurologist, answer commonly asked questions from our community focused on adults living with hydrocephalus. This Ask the Expert NPH Video Series was made possible through the generosity of our industry partner Codman, a part of Integra Lifesciences who we thank for supporting this important program!

How Is Normal Pressure Hydrocephalus Treated

Although there is no cure for NPH, the symptoms can be managed through surgery. Surgery involves inserting a drainage system called a shunt. One end of the shunt — which is a long sturdy, flexible plastic tube — is placed into one of the brain’s ventricles. The other end is tunneled under the skin to another area of the body, usually the lower part of the abdomen.

The shunt allows the excess cerebrospinal fluid to drain from the brain and be absorbed back into the body. A valve in the shunt keep the fluid flowing in the correct direction and at the right rate. The shunt remains in the person’s body for the rest of his or her life.

Tests And Diagnosis Of Normal Pressure Hydrocephalus

A neurologist and/or neurosurgeon will conduct a thorough physical exam and go through your medical history as a first step to diagnosing NPH.

Progressive gait problems with no clear cause may indicate NPH.

Other testing includes an MRI scan of the brain to look at the size of the ventricles. A CT scan can also be used for patients who cannot have an MRI. Other tests may be ordered to exclude diseases that can have similar symptoms as NPH.

If the scan shows enlarged ventricles, your neurologist or neurosurgeon will order a lumbar puncture to remove spinal fluid for testing.

Improvement in gait after this procedure may indicate that you are more likely to improve with the placement of a shunt.

Your doctor may also order a tube called a lumbar drain to drain the excess cerebral spinal fluid over a period of several days. This test requires that the patient be evaluated in a hospital with staff trained to manage these catheters to prevent complications such as infection or spinal injury. Again, improvement in gait after this procedure may indicate that you are more likely to improve with the placement of a shunt.

In addition to a neurologist and/or neurosurgeon, neuropsychologists may help with the diagnosis by analyzing specialized memory tests that help identify problem areas of memory and thinking.

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Treatment For Normal Pressure Hydrocephalus

Because theres no cure for this condition, treatment for normal pressure hydrocephalus is designed to reduce symptoms. Many of those symptoms can be effectively managed through surgical procedures. The goal is to place a shunt in the brain, which allows for excessive CSF to drain from the brain into the lower part of the abdomen. This shunt is placed into one of the ventricles where it collects CSF, which moves through the tube that is tunneled under the skin.

As the fluid drains off the brain, symptoms will lessen significantly. There are some risks to this procedure. For example, in some individual, infection and excessive bleeding can occur during the procedure. Most often, these complications are minor and the benefits are numerous.

Causes Of Normal Pressure Hydrocephalus

Several factors contribute to excess fluid build-up in the brain ventricles and these may include:

• Brain surgery

• Problems with vision
• Mild dementia that may involve loss in interest in day to day activities, challenges completing routine tasks as well as short-term memory loss and forgetfulness
• Having trouble walking, falling, changes in the way a person walks, poor balance, and getting stuck or freezing when a person wants to walk

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What Are The Symptoms Of Nph

The hallmark symptoms of normal pressure hydrocephalus include:

• A decline in cognitive skills, in the form of mild dementia that involves loss of interest in daily activities, forgetfulness, difficulty completing routine tasks and short-term memory loss.
• A decline in thinking skills that include overall slowing of thought processes, apathy, impaired planning and decision-making, reduced concentration, and changes in personality and behaviour are other features.
• Difficulty walking- sometimes compared to the way a person walks “on a boat,” with the body bent forward, small steps, legs held wide apart, feet moving as if they’re “glued to the deck, and difficulty making turns.
• Urinary urgency followed by loss of bladder control, which tends to appear somewhat later in the disease than difficulty walking and cognitive decline.

Management Of Normal Pressure Hydrocephalus

MEG VERREES, M.D., and WARREN R. SELMAN, M.D., Case Western Reserve University, Cleveland, Ohio

Am Fam Physician. 2004 Sep 15 70:1071-1078.

• References

The diagnosis of normal pressure hydrocephalus depends on symptom profile, presence of radiographic features, and the outcome of diagnostic tests. Although numerous techniques are used to identify patients who are likely to have NPH and various means are used to identify those patients most likely to respond to treatment, no definitive method exists to prove diagnosis. Cerebrospinal fluid diversion accomplished via placement of a ventriculoperitoneal shunt is the most common treatment.

Examination of the results of multiple studies yields a wide variation in patient response to shunting.

Examination of the results of multiple studies yields a wide variation in patient response to shunting.

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What Is The Prognosis After Surgery

Symptom improvement after shunt surgery to treat NPH is impacted by a number of variables. Its estimated that more than 80% of those properly diagnosed with NPH and screened for shunt responsiveness will experience rapid improvement in their condition, although it may take weeks or months to see the full benefits of the procedure. Physical therapy to address gait and balance impairments is important to assist with return to a safe and independent gait as well as progress to independent functioning in the community.

Early diagnosis is typically an indicator of successful treatment, but even those patients who have had symptoms for years may improve with treatment.

Youre not alone. The journey with NPH can be frustrating and unpredictable. For those living with NPH and their caregivers, staying informed about the condition is essential to managing care. The challenges of living with a chronic illness or caring for a chronically ill parent or spouse are stressful for all involved. Adults with hydrocephalus may resent their dependence on a spouse, child, or another family member. Acknowledging emotional responses to this chronic and potentially disabling condition can help all those involved.

We provide essential tools and resources that enable you to have more control of your life. There is a large community across the country that is engaged and connected through the Hydrocephalus Association ready to support you and your family.

What Are The Symptoms Of Normal Pressure Hydrocephalus

There are three classic symptoms of normal pressure hydrocephalus :

• Difficulty walking. This problem can be mild or severe. In many cases, people with NPH have trouble picking up their feet. Some describe it as feeling like their feet are stuck to the floor. This can lead to a shuffling walk and problems going up stairs and curbs. It also increases the risk of falling.
• Dementia. This often involves confusion, short-term memory loss/forgetfulness, trouble paying attention, changes in mood, and a lack of interest in daily activities.
• Problems with bladder control. Problems include urinary incontinence , frequent urination, and a strong feeling of needing to urinate.

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Normal Pressure Hydrocephalus Outlook

NPH is a progressive condition, meaning that the symptoms gradually worsen if not treated. In general, the outlook depends on the cause of the hydrocephalus and whether you are a candidate for surgery. Some people improve dramatically after surgery, while others do not. Some are not candidates for surgery. Those who are not candidates for surgery have few treatment options available.

If you have NPH, you should have regular visits with your neurologist or neurosurgeon. These visits allow the doctor to monitor your symptoms. Changes in symptoms may require adjustments in care.

Prevalence Prognosis And Definition

Normal pressure hydrocephalus is a relatively rare disorder characterized by enlargement of the ventricles, a gait disorder, incontinence, and cognitive impairment. Although some studies have suggested that up to 5% of patients with dementia have normal pressure hydrocephalus, other studies have found the prevalence to be closer to 1%, which is consistent with our experience of patients referred to a memory disorders clinic . It may, however, be underdiagnosed in the general population one study showed that 5.9% of individuals 80 years and older met criteria for normal pressure hydrocephalus .

Christopher M. Filley, in, 2002

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Brain Matters: Dementia Caused By Normal Pressure Hydrocephalus Can Be Reversible

As we age, one of the concerns is the potential onset of dementia. As we have learned from previous Brain Matters columns there are definitely some lifestyle adjustments that can be made to help stave off cognitive decline.

A small percentage of patients with dementia may have a brain condition called normal pressure hydrocephalus . The good news here is that with the appropriate interventions, the dementia can be reversible.

Normal pressure hydrocephalus develops in older patients and is the result of cerebrospinal fluid build up in structures called ventricles in the brain. In an unaffected brain, the fluid in the ventricles circulates and drains within the nervous system, bathing and cushioning the brain and spinal cord. In NPH, the fluid accumulates, enlarging the ventricles and causing decreased function of the brain.

The triad of symptoms associated with NPH includes a specific type of walking difficulty , urinary incontinence and memory loss. If you suspect NPH, your physician can do a work up which includes an office evaluation as well as imaging studies such as an MRI or CT scan to confirm a diagnosis. If there is a suspicion of NPH, a confirmatory test is necessary a lumbar puncture to drain cerebrospinal fluid followed by a memory and walking evaluation.

Wernicke’s Encephalopathy And Korsakoff’s Syndrome

A deficiency in thiamine is often, but not always, caused by alcohol abuse and can lead to Wernicke’s encephalopathy and Korsakoff’s syndrome. Wernicke’s encephalopathy is an acute condition of confusion, abnormal vision and eye movements, and problems with balance and body control. This condition is sometimes reversible with emergency treatment at the hospital.

Korsakoff’s syndrome is typically a long-term condition that sometimes follows an incident of Wernicke’s encephalopathy. It more closely resembles dementia’s symptoms and includes confusion, memory loss, hallucinations, and confabulation .

According to the Alzheimer’s Association, about 25% of people with Wernicke-Korsakoff syndrome will fully recover.

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What Causes Dementia

Dementia involves the damage or death of brain cells which can occur in multiple areas of the brain. Depending on the area of the brain affected it can affect people differently and it can worsen over time. Dementia can be caused by repetitive head injuries, some types of traumatic brain injuries, stroke, brain tumor or a disease such as Alzheimers, Lewy Body, Parkinsons or Huntingtons can all damage brain cells and lead to dementia. The causes of some dementias are easier to understand in terms of how they affect the brain and lead to dementia:

How Is Nph Diagnosed

There is no single test that is diagnostic of normal pressure hydrocephalus. Although the three hallmark symptoms of cognitive decline, walking difficulty and loss of bladder control are considered the classic signs of this disorder, not everyone with NPH has all of these symptoms.

Brain imaging to detect enlargement of the ventricles, often with magnetic resonance imaging , plays a key role in diagnosing NPH. Several brain disorders, including Alzheimer’s disease, can cause overall brain tissue shrinkage that makes the ventricles look larger than normal. In NPH, although the ventricles are enlarged, brain tissue may not appear shrunken.

Since the symptoms of NPH may overlap with those of Alzheimer’s and other dementias, it is recommended that a person with suspected NPH undergo examination by a neurologist experienced in evaluating brain disorders that affect movement, thinking skills and physical functions. FDG PET may serve as a useful diagnostic biomarker in evaluating a person for NPH.

While AD pathology is an important comorbid disease confounding the cognitive features of NPH, Parkinson disease and other neurodegenerative parkinsonian syndromes causing walking or gait abnormality are important conditions to consider when evaluating NPH.

In some cases, normal pressure hydrocephalus is caused by other brain disorders such as haemorrhages, infections or inflammation. But in most cases, the cause of fluid accumulation is unknown.

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Causes And Risk Factors Of Normal Pressure Hydrocephalus

Its not fully understood what causes normal pressure hydrocephalus. The cause of the buildup of the CSF remains unknown. There is limited research suggesting that it is brought on by some type of bleeding around the brain. This may occur, for example, after a stroke. It may also occur if there is a head injury. There are also indications that those who develop meningitis are more likely to develop this condition as well. In other cases, there is no known cause.

What Are The Risks

No surgery is without risk. Potential complications from the surgery itself include bleeding in the brain or ventricles, infection, seizures, and problems with anesthesia.

Complications that can occur later include shunt malfunction from a clog or infection. This causes CSF to build up and a return of the original symptoms. Call the doctor if you experience abnormal symptoms. Blockages can often be fixed. In rare cases, the shunt may need to be replaced.

If the ventricles decrease in size too rapidly, the brain can pull away from the skull and tear small blood vessels. This can cause blood clots around brain . Programming of the shunt to drain CSF at the proper rate and regular follow up visits with the doctor ensures the system is working optimally.

Some symptoms of shunt malfunction:

• Difficulty walking/gait disturbances
• Fever
• Redness along the shunt tract

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What Is The Current Treatment

Surgical treatmentsHydrocephalus is treated with one of two surgical options:

• A shunt is surgically inserted into the brain and connected to a flexible tube placed under the skin to drain the excess fluid into either the chest cavity or the abdomen so it can be absorbed by the body.
• Endoscopic Third Ventriculostomy improves the flow of CSF out of the brain. A tiny hole is made at the bottom of the third ventricle and the CSF is diverted there to relieve pressure. Sometimes this is done in conjunction with choroid plexus cauterization to try and decrease the production of CSF. Choroid plexus cauterization uses electric current to burn the CSF-producing tissue in the lateral ventricles in the brain, so it produces less CSF.

Shunt systems generally function well but they can fail to properly drain the CSF due to mechanical failure or infection. When this happens the CSF once again begins to build up in the brain and earlier symptoms may recur. To reduce the buildup of CSF, the clogged shunt system is replaced to restore drainage of CSF. Shunts require monitoring and regular medical checkups. Multiple surgeries may be needed to repair or replace a shunt throughout a persons lifetime. Seek medical help immediately if symptoms develop that suggest the shunt system is not working properly.Signs and symptoms of shunt malfunction may include:

• headache
• reoccurrence of hydrocephalus symptoms.

Causes Of Potentially Reversible Dementia Symptoms

Worried that a loved one has Alzheimer’s disease? While you may be right, you should be sure to have a physician conduct a thorough evaluation to be certain. Some illnesses and conditions that look and act like Alzheimer’s are reversible with appropriate treatment.

Here are 10 potentially reversible causes of dementia symptoms:

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What Happens After Surgery

The patient remains in the hospital 2 to 3 days. At first, the area over the shunt may be raised up, but as the swelling goes away, the shunt is usually not noticeable. Spinal headaches are caused by leakage of CSF around the catheter or shunt site. Lie flat and drink plenty of caffeinated noncarbonated fluids .

Patients should take it easy for several weeks after surgery, with no bending, twisting, heavy lifting, or wearing of tight-fitting hats. Incisions need time to heal. Patients may shower as directed by their surgeon but should not take a tub bath or submerge in water for 4 weeks. Incisions should be patted dry with a soft towel to avoid irritation.

If the patient has a severe headache, vomiting, and a stiff neck that prevents lowering the chin to the chest ââ¬â this is an emergency ââ¬â go to a hospital. These are signs of bleeding in the brain.

Overview And Facts About Normal Pressure Hydrocephalus

Normal pressure hydrocephalus is a disease that most commonly occurs in older patients who may have a number of underlying chronic diseases that may cause gait difficulties, dementia and urinary incontinence.

NPH is a brain disorder in which excess cerebrospinal fluid builds up in the ventricles .

This buildup can cause thinking and reasoning issues, difficulty walking and loss of bladder control. Another name for NPH is chronic extra ventricular hydrocephalus.

NPH is often confused with other memory disorders and diseases. Because of these other underlying diseases, NPH is not always diagnosed early.

Alzheimers disease and Parkinsons disease are among the most well known degenerative brain diseases that may be confused with NPH.

Other chronic diseases that can cause gait problems include arthritis, peripheral neuropathy , dizziness related to inner ear disorders, narrowing of the spine in the neck or low back regions.

Multiple strokes can also cause dementia, gait difficulty and urinary problems.

There are two main types of NPH, primary and secondary:

• Primary NPH: No obvious cause can be identified
• Secondary NPH: An identifiable cause is found, such as a history of brain tumor, history of bleeding in the brain, previous history of meningitis or history of head injury.

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