September 15, 2026

@michaelokun

Could we be missing one of the most treatable causes of walking and thinking problems in older adults. Normal pressure hydrocephalus (NPH) is a condition where the brain’s fluid spaces enlarge and can disrupt walking, bladder control and thinking. Maroufi and colleagues describe in a new review in JAMA why idiopathic NPH deserves our attention, particularly because it can mimic Parkinson’s disease and Alzheimer’s disease and, importantly, symptoms can improve following treatment. Key points: - Gait problems are frequently the earliest clue, occurring in 85% to 95% of folks, while urinary symptoms and cognitive changes are also common. - Diagnosis requires putting the clinical picture together w/ brain imaging, and removing CSF through a large-volume lumbar puncture can help predict who may respond to a shunt. - Following shunting, gait improves in approximately 70% to 90% of folks, while cognitive and urinary symptoms improve in approximately 50% to 70%. My take: NPH is important because it sits at the intersection of neurology, neurosurgery and aging, and it can look remarkably like Parkinson’s disease, dementia or simply getting older. We should resist prematurely labeling an older person w/ walking, thinking and bladder changes as having an untreatable neurodegenerative disease. NPH is one of those diagnoses we do not want to miss. However, be careful of jumping to a shunt as there can be many complications of shunt therapy. Make sure you have examined the risk-benefit profile for each individual. Here are 5 points that resonated w/ me: 1- Think NPH when gait slowing, falls, cognitive changes and urinary urgency begin clustering together. 2- The classic triad does not need to be complete, and gait trouble may arrive first. 3- MRI findings are important, however imaging alone cannot reliably tell us who will improve following treatment. 4- A large-volume spinal tap and objective measurement of gait before and after CSF removal can provide an important clue about shunt responsiveness. 5- Perhaps the biggest message is simple: recognize NPH early because this is one neurological syndrome where identifying the right folks can potentially restore walking.