Normal Pressure Hydrocephalus: A Care Staff Guide

Normal pressure hydrocephalus (NPH) is a rare condition in which fluid builds up in the cavities of the brain and gradually causes problems with walking, thinking and bladder control. It is often mistaken for dementia, Parkinson's disease or simply old age, yet it is one of the few causes of dementia-like symptoms that can sometimes be treated with surgery. For care staff, who see people day after day and notice slow change, recognising the pattern and asking for assessment can make a real difference. This guide draws on information from Alzheimer Society of Canada and a clinical review in the Cleveland Clinic Journal of Medicine. It is general information, not clinical advice.

The classic triad

The three main symptoms are problems with walking (gait), dementia-type changes in thinking, and loss of bladder control. The Alzheimer Society of Canada describes the walking difficulty as people not lifting their feet, as if their feet are stuck to the ground. Cognitive changes include forgetfulness, memory loss and impaired decision-making, and bladder control problems also develop. The clinical review notes that gait difficulty is usually the first symptom, appearing in 89 per cent of the diagnosed cases it describes. Staff may therefore notice shuffling, a wide-based or "magnetic" gait, difficulty turning, frequent falls and hesitation at doorways well before anything changes in memory. Our guide to falls prevention under CQC Regulation 12 explains how to respond to falls, and any unexplained change in gait should trigger a medical review.

Who gets it

According to the Alzheimer Society of Canada, symptoms appear mainly in people over 60, but NPH can occur at any age, and it is a rare neurological condition. It can arise without a known cause, or it can follow a brain injury, bleed, infection or surgery. If a person has a history of brain injury, see our guide to acquired brain injury in care home residents.

How NPH differs from Alzheimer's and Parkinson's

The Cleveland Clinic review explains that Alzheimer's disease usually shows a slow, progressive decline in memory and function with prominent cortical problems such as difficulty finding words or carrying out learned movements, while NPH produces changes in thinking and processing that are deeper and without those cortical deficits. In Parkinson's disease, features include a resting "pill-rolling" tremor, slowness, stiffness and freezing, whereas the walking problem in NPH has a distinct "magnetic" quality. The review adds that Parkinson-like features seen in late NPH typically do not respond to levodopa. Because symptoms overlap, only a specialist assessment can tell these conditions apart, and some people have more than one at once.

How it is diagnosed

The Alzheimer Society of Canada says there is no single test for NPH. Doctors look at the pattern of symptoms and medical history, use brain imaging (MRI or CT) to look for enlarged fluid spaces called ventricles, and may do a spinal tap to measure fluid pressure and see whether walking improves afterwards. Neuropsychological testing may also assess how thinking is affected. The Cleveland Clinic review cautions that the tap test is imperfect: a positive result is reasonably reliable, but a negative result does not rule out NPH, because the false-negative rate was around 50 per cent in the studies it described.

Treatment: shunt surgery

The main treatment is a ventriculoperitoneal shunt, a tube that drains excess cerebrospinal fluid from the brain to the abdomen. The Alzheimer Society of Canada says the procedure is most likely to improve walking and may also improve thinking and bladder symptoms, and notes that there is currently no known non-surgical cure. The Cleveland Clinic review, published in 2006, reported that symptoms improved substantially in only 30 to 50 per cent of patients, that dementia responded least well, and that about 38 per cent experienced complications, with 22 per cent needing further surgery and 5 to 8 per cent suffering death or severe disability. Those figures are from an older review and techniques have changed, so staff should not quote them to families and should leave outcome discussions to the specialist team.

What care staff can do

• Notice and record the pattern. Note when walking changed, how often falls and accidents happen, and when memory or continence worsened. A dated timeline helps clinicians more than a single description.
• Ask for medical review. If walking, thinking and bladder control are all affected, tell the GP and ask whether a neurology or memory service referral is appropriate.
• Rule out other causes. Infection, medicines and delirium can also cause new confusion; see our guide to the 4AT delirium screening tool.
• Support continence with dignity. Regular toileting prompts, clear routes to the toilet and suitable clothing reduce accidents without blaming the person.
• Keep the person moving safely. Follow physiotherapy advice, use appropriate aids and make the environment trip-free.

After a shunt

People with a shunt need follow-up and a clear plan. Staff should know the signs that a shunt may not be working, such as new or returning headache, vomiting, drowsiness, confusion, worsening walking, or swelling or redness along the shunt tract, and should seek urgent medical advice if they appear. Make sure the person's shunt is recorded in their care plan and in hospital documents, and that any scans or procedures take it into account.

Frequently asked questions

Is NPH a type of dementia?

It can cause dementia-like symptoms, but it is a different condition and is sometimes treatable, which is why proper assessment matters.

Can everyone with NPH be treated?

Not everyone is suitable for or benefits from a shunt. The specialist team weighs the likely benefits against the risks for each person.

What training helps staff recognise changes like this?

Dementia awareness, falls prevention and recognising deterioration all help. Browse the Learnsignal CPD hub for healthcare compliance courses.

Sources: Alzheimer Society of Canada, Normal pressure hydrocephalus; Cleveland Clinic Journal of Medicine review of normal pressure hydrocephalus (2006). This article is general information, not clinical advice.