Normal Pressure Hydrocephalus: A Treatable Cause of Dementia-Like Symptoms
Normal Pressure Hydrocephalus: The Treatable Dementia You Can't Afford to Miss
A comprehensive guide for clinicians and patients — with the latest RCT evidence from the PENS trial (NEJM 2025) and DRAIN trial (Lancet Neurology 2026)
Normal Pressure Hydrocephalus (NPH) is one of the few reversible causes of dementia-like symptoms. When recognized early and treated with shunt surgery, up to 75% of patients show meaningful gait improvement — yet the diagnosis is frequently missed or delayed.
NPH is a form of communicating hydrocephalus in which excess cerebrospinal fluid (CSF) accumulates in the brain's ventricles, enlarging them — yet the CSF opening pressure remains normal or only minimally elevated. It predominantly affects adults over 60 years of age and is classified as idiopathic (iNPH) when no underlying cause is identified, or secondary when it follows subarachnoid hemorrhage, traumatic brain injury, CNS infection, or other insults.
The Classic Hakim-Adams Triad
Symptoms develop insidiously over months to years. The full triad is present in approximately two-thirds of patients at the time of diagnosis — but gait disturbance nearly always appears first.
Gait Disturbance
Wide-based, slow, magnetic gait with decreased step height and stride length; difficulty initiating walking; freezing; turning instability. Gait velocity typically ≤1 m/s. Leg strength, sensation, and reflexes are usually normal.
Present in >90%
Cognitive Impairment
Subcortical pattern: psychomotor slowing, impaired short-term memory, and difficulty with activities of daily living. Can closely mimic Alzheimer's disease or other neurodegenerative dementias.
Present in ~80%
Members Only
This review continues for members
The remainder of this article — the full clinical reasoning, evidence-strength tables, and complete reference list — is available to APOE4 Insights members.
- Physician-authored, evidence-calibrated clinical reviews
- Explicit about what the data do and do not support
- No industry sponsorship, no supplement affiliates
$19 for three months
Already a member? Log in