Normal Pressure Hydrocephalus: Recognizing Gait Issues, Cognitive Changes, and Shunt Treatment
Jan, 22 2026
Imagine waking up one day and noticing you’re shuffling your feet more than usual. You forget where you put your keys. You start having accidents you never had before. Your doctor says it’s just aging. But what if it’s not? What if it’s something treatable - something that could bring back your independence?
That’s the reality for many older adults with normal pressure hydrocephalus (NPH). It’s not dementia. It’s not Parkinson’s. It’s a hidden neurological condition that mimics both - but can be reversed with surgery. Yet, up to 60% of cases are missed. People live for years thinking they’re just slowing down, when the truth is, their brain is filling with fluid - not because of high pressure, but because the fluid won’t drain properly.
What Exactly Is Normal Pressure Hydrocephalus?
NPH is a buildup of cerebrospinal fluid (CSF) in the brain’s ventricles. These are natural spaces that normally hold and circulate fluid to cushion the brain. In NPH, the fluid doesn’t get absorbed the way it should. The pressure stays normal - hence the name - but the ventricles swell, squeezing nearby brain tissue. This leads to three classic symptoms: trouble walking, memory and thinking problems, and loss of bladder control.
The condition mostly hits people over 60. About 1 in 200 adults over 65 have it. In nursing homes, that number jumps to nearly 6 in 100. Yet, most never get tested. Why? Because doctors often assume it’s Alzheimer’s or just old age. But unlike Alzheimer’s, where memory fades slowly and walking stays normal until late, NPH starts with walking. You might feel like your feet are stuck to the floor - a "magnetic gait." You take small, shuffling steps. You lose balance. Turning becomes hard. This isn’t weakness. It’s your brain’s signal system getting crushed by fluid.
The Three Signs You Can’t Ignore
Every case of NPH shows at least one of these three signs. But only about 30% show all three at once. That’s why it’s so easy to miss.
- Gait disturbance: This is the first and most consistent sign. In nearly every diagnosed case, walking changes are the earliest red flag. People describe it as feeling "drunk" without drinking. They drag their feet. They can’t start walking easily. They take short, slow steps. Even a simple 10-meter walk test can show a 30% drop in speed compared to their own past performance.
- Cognitive impairment: This isn’t forgetting names. It’s losing focus, slowing down, forgetting why you walked into a room. You might still remember your kids’ birthdays but struggle to pay bills or follow a conversation. Neuropsych tests show damage to the frontal lobes - the part of the brain that handles planning, decision-making, and attention. This looks like dementia, but it’s different. It’s reversible.
- Urinary incontinence: This usually comes later. People don’t feel the urge to go, or they can’t make it to the bathroom in time. It’s not a bladder problem. It’s the brain losing its ability to control the signal.
These symptoms creep in slowly. Over months. Sometimes years. That’s why families and doctors brush them off. But here’s the kicker: if you catch it early, you can fix it.
How Do You Diagnose It?
There’s no single blood test. No MRI that says "NPH" in big letters. Diagnosis takes a few steps - and most doctors don’t know them all.
First, a brain scan - either CT or MRI. It shows if the ventricles are enlarged. A key measurement called Evan’s index (ventricle-to-brain ratio) over 0.3 is a strong clue. Periventricular white matter changes and flow voids near the aqueduct also point to NPH.
Then comes the CSF tap test. A doctor removes 30-50 milliliters of spinal fluid with a needle in your lower back. It’s not painful. You lie flat for 30 minutes. Then they measure your walking speed again. If you walk 10% faster - or if your balance improves - that’s a sign your brain will respond to a shunt. Studies show this test predicts shunt success with 82% accuracy.
Some centers use a longer test: external lumbar drainage. A small catheter stays in your back for 2-3 days, slowly draining fluid. If your symptoms improve during that time, your chances of success with surgery jump to 89%.
And here’s the thing: if you have other conditions - like Alzheimer’s or Parkinson’s - which happens in 1 in 3 NPH patients - the diagnosis gets even trickier. That’s why experts now recommend testing for NPH in every older adult with unexplained walking problems, even if they already have another diagnosis.
Shunt Surgery: The Only Treatment
The only cure for NPH is surgery - a ventriculoperitoneal (VP) shunt. It’s a tiny tube placed in the brain’s ventricle, connected to another tube that runs under your skin to your abdomen. A valve in between controls how much fluid drains. The fluid gets absorbed by your body like it’s supposed to.
The surgery takes about an hour. Most people go home in 2-3 days. Recovery is quick. Many report feeling better within 48 hours. One patient on a support forum said his walk time dropped from 28 seconds to 12 seconds after surgery. Another regained bladder control after 18 months of accidents.
But it’s not magic. About 20-30% of shunts don’t help. Why? Maybe the diagnosis was wrong. Maybe the brain was too damaged. Or maybe the valve pressure wasn’t set right. Shunts can also fail - 15% break or get blocked within two years. Infections happen in about 8.5% of cases, especially in people over 80.
That’s why patient selection matters. If you didn’t improve during the CSF tap test, your chance of success drops to 42%. If you did? It’s 89%. That’s why testing before surgery isn’t optional - it’s essential.
Who Gets Better? And How Fast?
Most patients see the biggest changes in walking - 76% improve significantly. Cognitive gains are slower but still common: 62% report clearer thinking. Bladder control improves in 58%. And 89% of patients say they’re glad they had the surgery, even if they needed a revision later.
Speed matters. If you wait more than a year after symptoms start, your chance of full recovery drops by 30%. The brain adapts to the pressure. The longer it’s compressed, the harder it is to bounce back. That’s why early testing saves not just function - but independence.
One woman in her late 70s, after years of being told she was "just forgetful," got a shunt. Within a week, she was cooking again. Within a month, she was walking her dog. She told her neurologist, "I didn’t know I was still alive until I got this surgery."
Why Is NPH So Often Missed?
Because it looks like other things.
Alzheimer’s? It starts with memory, not walking. Parkinson’s? Tremors and stiffness, not magnetic gait. Vascular dementia? Symptoms come after strokes - step by step. NPH? Everything creeps in together, slowly, without a clear trigger.
And the system doesn’t help. Insurance often denies the CSF tap test or lumbar drainage - 37% of patients face prior authorization denials. Primary care doctors rarely refer to neurology. Neurologists don’t always think of NPH. Surgeons wait for perfect scans. By the time someone gets tested, it’s too late.
Experts say: if you’re over 60 and your walking has changed - especially if you’re also having memory issues - ask for an NPH evaluation. Don’t wait for a diagnosis. Push for it.
What’s New in NPH Care?
There’s progress. In 2022, the FDA approved a device that measures CSF outflow resistance - helping doctors know for sure if the fluid isn’t draining. In 2023, a smartphone app called the iNPH Diagnostic Calculator uses 12 clinical factors to predict shunt success with 85% accuracy.
Researchers are also testing blood and spinal fluid biomarkers. Early trials show a 92% sensitivity for spotting NPH without any invasive tests. That could change everything. Imagine a simple blood test telling you if your gait problem is NPH - not dementia.
And the shunt technology is improving. New programmable valves let doctors adjust pressure non-invasively with a magnet - no more second surgeries just to tweak the valve. Companies like Medtronic, Codman, and Miethke are leading the way.
But the biggest breakthrough isn’t a device. It’s awareness. More doctors are learning to look for NPH. More families are asking the right questions. And that’s saving lives.
What Should You Do Next?
If you or someone you love is over 60 and showing signs of slow walking, memory slips, or bladder issues - don’t accept "it’s just aging."
- See a neurologist. Bring a video of their walking if you can.
- Ask specifically: "Could this be normal pressure hydrocephalus?"
- Request a brain MRI and a CSF tap test.
- If the tap test shows improvement, talk to a neurosurgeon about a shunt.
- Don’t delay. The sooner you act, the better the chance of recovery.
NPH is rare. But it’s one of the few causes of dementia that can be reversed. You don’t need to lose your independence. You just need someone to look closely - and act fast.
Is normal pressure hydrocephalus the same as dementia?
No. NPH causes dementia-like symptoms, but it’s not a neurodegenerative disease like Alzheimer’s. In NPH, brain damage comes from fluid pressure - not cell death. And unlike Alzheimer’s, NPH can be reversed with surgery. Many patients regain memory, walking, and bladder control after a shunt. That’s why it’s called a "reversible dementia."
Can NPH be diagnosed with just an MRI?
An MRI can show enlarged ventricles and other signs like periventricular edema, but it can’t confirm NPH on its own. Many older adults have enlarged ventricles without NPH. The key is matching those scans with symptoms - especially gait changes - and confirming with a CSF tap test. Without clinical improvement after fluid removal, an MRI alone isn’t enough for diagnosis.
How successful is shunt surgery for NPH?
For patients who pass the CSF tap test, shunt surgery improves symptoms in 70-90% of cases. Gait improves most often - around 76% of patients walk better. Cognitive and bladder symptoms improve in about 60%. But if the tap test shows no improvement, success drops to under 50%. Shunt failure or infection happens in about 15-20% of cases, but most complications can be fixed with adjustments or revisions.
How long does it take to recover after shunt surgery?
Most people go home in 2-4 days. Many notice walking improvements within 48 hours. Full recovery takes 6-12 weeks. Cognitive gains may take longer - up to 3 months. Physical therapy helps speed up walking recovery. Regular follow-ups with a neurosurgeon are needed for the first 6 months to adjust the shunt valve if needed.
Can NPH come back after shunt surgery?
The condition doesn’t "come back," but the shunt can fail. Shunts can get blocked, infected, or need pressure adjustments. About 15% need a revision within two years. Some patients need multiple adjustments over time. But the underlying NPH is treated - the shunt just keeps the fluid draining. With proper care, most patients stay improved for years, even decades.
Is NPH covered by Medicare?
Yes. Medicare covers shunt surgery and most diagnostic tests - including MRI and CSF tap tests - if they’re medically necessary. However, many patients face delays because insurers deny coverage for lumbar drainage or require prior authorization. The 2023 National Coverage Determination requires documented improvement after CSF removal before approving surgery, so keeping records of test results is crucial.
Are there non-surgical treatments for NPH?
No. Medications like cholinesterase inhibitors used for Alzheimer’s don’t work for NPH. Physical therapy helps with walking but doesn’t fix the root cause. The only proven treatment is surgical shunt placement. Research is ongoing into non-invasive drainage methods and biomarkers, but none are approved yet. If you’re told medication will help, ask for evidence - it’s unlikely to be effective.
Final Thought
NPH doesn’t make headlines. It doesn’t have a pink ribbon or a walkathon. But it’s real. And it’s treatable. For every person told they’re just getting older, there’s a chance they’re one test away from getting their life back. Don’t let silence be the reason they lose it.