Mind Matters - April 2006
Written by Ron Sterling, M.D. and Published in Northwest Prime Time Magazine

Spread the NPH Word
by Ron Sterling, M.D. -- April 2006

    Dear Dr. Ron:

      My 76 year-old mother has had what I feel is an almost miraculous cure. For a couple of years, her mental functioning had gone gradually downhill. She would lose things, but accuse people of stealing them. However, she was able to go for long walks and not get lost. I thought she was just having a difficult time adapting to living alone after her husband died. She also had problems with urinary accidents and she was unsteady.

      I was finally able to get enough time off from work to travel to where she lives and make sure she made it to doctor appointments and followed-up. It took almost a month of work, but I found out she had a mostly curable problem that was not just related to old age. She had normal pressure hydrocephalus (NPH). I was shocked. I had never heard of such a thing. After a lot of tests, the doctors put a shunt in to fix the problem and her forgetfulness, unsteadiness and incontinence almost completely disappeared. Could you please spread the word about NPH and its treatment? -- Signed: Concerned About Others.

    Dear Concerned:

      Thank you for writing! I wrote briefly about normal pressure hydrocephalus (NPH) in my October 2004 column entitled "Reversible Dementias." However, I did not go into detail at that time. Although NPH accounts for about 5% of all cases of dementia, it is significant because, if treated in a timely manner, most symptoms can be reversed.

      NPH is felt to be greatly underdiagnosed. Since the symptoms of NPH do not show up all at the same time, it can be difficult to diagnose. Often, each symptom is investigated independently as they show up and the whole picture does not get put together until later. Often, walking problems and incontinence are seen as normal aging problems and family members may not get appropriately concerned. In addition, the diagnosis has only been made since 1965. NPH occurs equally in both males and females and almost always after age 60.

      However, the major diagnostic symptoms of NPH are clear-cut and easy to remember -- (1) gait disturbance (a change in walking or standing); (2) urinary incontinence (or urgency and frequency); and, (3) dementia. More often than not, the symptoms show up in that order in the course of the disease. The disorder might be better named "GUD" Triad.

      In fact, the name NPH is misleading because it is highly likely that in the course of the disease there is an early or recurring period of time when the cerebrospinal fluid (CSF) pressure is much higher than normal before it returns to normal. The symptoms of NPH are caused by the "crushing" of brain tissue due to the expansion of pools of CSF (ventricles) inside the brain. The entire brain and spinal cord system are bathed by the CSF which protects them. Deep inside the brain, there are several pools of CSF. If, for some reason, the CSF cannot circulate out of the ventricles, they will expand and crush brain tissue. Once the ventricles expand to accommodate the increased fluid, the pressure goes back to normal.

      NPH cannot always be treated. When it can be treated, the treatment consists of implanting a shunt in the brain that drains excess CSF into the abdominal cavity. Your mother's experience of showing remarkable improvement after a shunt was surgically installed happens for about 60% of patients who are treated. The percentage of improvement is greater if certain criteria are met before a shunt is installed.

      I hope this helps. Since this is a complex subject, I recommend viewing some of sites that are listed below. -- Best wishes, Dr. Ron.

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