Normal-Pressure Hydrocephalus in Adults: What Families Should Know
As adults age, changes in mobility, memory, balance, and bladder function are often attributed to aging or to more familiar conditions such as arthritis, Parkinson's disease, stroke, or dementia. In some cases, however, a combination of these changes may signal a less familiar neurological condition: normal-pressure hydrocephalus (NPH).
NPH is a disorder of cerebrospinal fluid (CSF) circulation in which the brain's ventricles become enlarged. It occurs predominantly in older adults and can affect gait, cognition, and urinary function. What makes NPH particularly important is that, unlike many disorders with similar symptoms, appropriately diagnosed NPH can be treatable, and selected patients may experience meaningful improvement after treatment.
At the same time, NPH is frequently oversimplified. Enlarged ventricles on a brain scan do not, by themselves, establish the diagnosis, and symptoms that resemble NPH can have many other causes. Diagnosis requires clinical judgment, neurological examination, brain imaging, and, in appropriate patients, assessment of the response to CSF drainage.
For families, understanding the condition can help turn an unexplained change in an older person's function into a more productive conversation with the healthcare team.
Understanding Normal-Pressure Hydrocephalus
Cerebrospinal fluid circulates through the brain and spinal cord, providing cushioning and supporting the central nervous system. When CSF circulation or absorption is disrupted, fluid can accumulate within the brain's ventricles, causing them to enlarge.
In NPH, ventricular enlargement occurs without the sustained elevation in intracranial pressure typically associated with other forms of hydrocephalus. The term "normal pressure" therefore refers to pressure measurements that may remain within a relatively normal range; it does not mean that the condition is normal or clinically insignificant.
NPH may be idiopathic, meaning no clear initiating cause can be identified, or secondary, developing after conditions such as subarachnoid hemorrhage, traumatic brain injury, infection, or other disorders affecting CSF circulation.
The distinction is clinically relevant because the underlying cause can influence evaluation and management.
The Clinical Pattern: Walking, Thinking, and Bladder Function
The traditional clinical picture of NPH involves three areas:
Gait and balance
Cognitive function
Urinary control
Not every patient develops all three, and the severity and timing of symptoms vary.
Gait and balance
Changes in walking are often among the most important early clues. A person may develop a slower, shorter-stepped or shuffling gait, difficulty initiating movement, instability when turning, or increasing difficulty maintaining balance.
Families may notice that someone who previously walked independently now appears hesitant when taking the first step, takes markedly smaller steps, or has begun falling more frequently.
These changes can resemble Parkinsonian gait disorders, vascular disease, arthritis-related mobility limitations, or other neurological conditions. The distinction cannot be made reliably from appearance alone and requires clinical evaluation.
Cognitive changes
Cognitive effects may involve more than memory. Some individuals develop slowed information processing, reduced attention, difficulty planning or organizing activities, or a decline in executive functioning.
This can create an important diagnostic challenge because cognitive impairment in an older adult may be attributed to Alzheimer's disease or another dementia without considering other potentially treatable causes.
Importantly, NPH and a neurodegenerative disorder are not mutually exclusive. An individual can have more than one neurological condition.
Urinary symptoms
Urinary urgency, frequency, and eventually incontinence may occur. These symptoms are common in older adults for numerous reasons and are therefore not specific to NPH.
Their significance increases when they occur in combination with a characteristic gait disturbance and cognitive or functional changes.
Why NPH Can Be Difficult to Recognize
NPH is not diagnosed by symptoms alone.
A similar clinical picture can arise from several conditions that are common among older adults. A person with difficulty walking may have arthritis, neuropathy, Parkinson's disease, stroke-related impairment, medication effects, or a combination of conditions. Cognitive changes may reflect Alzheimer's disease, vascular cognitive impairment, medication effects, depression, sleep disorders, or other neurological disease.
This overlap is one reason NPH can be missed—and also why it should not be diagnosed casually.
Current expert guidance emphasizes integrating the clinical presentation with characteristic imaging findings, CSF testing when appropriate, and a differential diagnosis that considers neurodegenerative disease and secondary causes of hydrocephalus.
How NPH Is Diagnosed
There is no single test that establishes NPH in every patient.
Clinical and neurological assessment
The evaluation generally begins with a detailed medical history and neurological examination. Clinicians assess gait, balance, coordination, cognition, functional changes, and urinary symptoms while reviewing the timing and progression of those changes.
A family member or caregiver can be particularly valuable because gradual changes in cognition or daily functioning may be more apparent to others than to the individual experiencing them.
Brain imaging
MRI is the preferred imaging study for adults with suspected hydrocephalus. It can demonstrate ventricular enlargement and provide information that may help distinguish NPH from other structural or neurological conditions. CT can also identify ventricular enlargement and may be used when MRI is unavailable, contraindicated, or when rapid imaging is required.
One important point for families is that ventriculomegaly—enlarged ventricles—is not synonymous with NPH.
Ventricular enlargement can also occur when brain tissue has been lost because of aging, stroke, neurodegenerative disease, or other causes. This is sometimes referred to as hydrocephalus ex vacuo. Consequently, imaging findings must be interpreted in the context of the patient's symptoms and examination.
Specialists may evaluate additional imaging characteristics, including patterns of ventricular enlargement and other features that support a diagnosis of idiopathic NPH.
The CSF Tap Test
When NPH is suspected, clinicians may perform a lumbar puncture, or CSF tap test, in which a measured amount of cerebrospinal fluid is removed.
The patient's function is assessed before and after the procedure. Depending on the clinical setting, assessment may include gait speed, step length, balance, cognition, and urinary function.
A measurable improvement after CSF removal can provide useful evidence when determining whether a patient may benefit from shunt surgery.
However, the test is not interpreted in isolation. A lack of obvious improvement after one procedure does not necessarily settle the diagnosis in every patient. In selected circumstances, specialists may consider additional CSF drainage testing.
The 2026 expert consensus identifies the CSF tap test as an important component of preoperative assessment and recommends multidimensional evaluation of gait, cognition, and urinary function rather than relying on a single outcome measure.
Treatment: When Shunt Surgery May Be Appropriate
For appropriately selected symptomatic patients, the principal treatment for NPH is CSF diversion through a shunt.
The most common approach is a ventriculoperitoneal shunt, which diverts CSF from the brain's ventricles to the abdominal cavity, where the fluid can be absorbed. Shunt systems incorporate valves that regulate drainage, and some systems can be programmed to adjust the drainage setting over time.
The decision to proceed with surgery is individualized. Physicians consider the severity and pattern of symptoms, imaging, CSF testing, comorbidities, functional status, and the potential benefits and risks of surgery.
What improvement can patients expect?
The strongest and most consistent treatment response is often seen in gait and mobility, although individual outcomes vary.
Evidence has continued to develop. A 2024 Cochrane review concluded that CSF shunting probably improves gait speed and disability in the short term in people with idiopathic NPH, while evidence regarding cognition and some other outcomes was less certain.
More recently, a 2025 randomized, double-blind trial published in the New England Journal of Medicine found that active shunt treatment produced significantly greater improvement in gait velocity and gait/balance measures than placebo settings at three months among appropriately selected patients. The study did not find statistically significant differences in cognitive or bladder outcomes at that time point.
These findings reinforce an important point for families:
Successful treatment does not necessarily mean that every symptom will improve to the same degree or at the same rate.
For one patient, the most meaningful improvement may be walking more safely and independently. For another, cognitive or functional gains may be more important.
Risks and Long-Term Management
Shunt surgery is not without risk.
Potential complications include infection, bleeding, obstruction or malfunction of the shunt, over-drainage or under-drainage of CSF, and the possibility of requiring additional procedures.
The 2025 randomized trial documented adverse events associated with shunting, including subdural bleeding and positional headaches. Earlier American Academy of Neurology guidance likewise concluded that potential benefits must be weighed against surgical risks.
Patients who receive shunts generally require ongoing follow-up. Programmable systems may require adjustment, and new or recurrent symptoms may warrant evaluation for shunt malfunction or another medical or neurological condition.
This makes NPH management a process rather than a single procedure.
What Families Should Watch For
Families and caregivers are often the first to recognize a meaningful functional change.
Rather than simply reporting that an older relative is "declining," it can be helpful to document specific changes:
Mobility
Has walking speed changed?
Are the steps shorter or more shuffling?
Is it harder to initiate walking?
Has balance deteriorated?
Have falls become more frequent?
Cognition and function
Is the person slower when processing information?
Are familiar tasks becoming difficult to organize?
Has independence with medications, finances, cooking, or other activities changed?
Urinary function
Has urgency increased?
Are accidents occurring?
Did urinary changes develop around the same period as walking or cognitive changes?
The goal is not for families to diagnose NPH themselves. The goal is to provide the healthcare professional with a clear picture of what changed, when it changed, and how it is affecting daily life.
When to Seek Medical Attention
Progressive changes in walking, balance, cognition, or bladder control should be discussed with a healthcare professional, particularly when several occur together.
NPH, however, is generally a gradual condition. Sudden neurological symptoms should not be assumed to represent NPH.
Sudden weakness or numbness, facial drooping, difficulty speaking, sudden severe confusion, sudden loss of balance, seizure, loss of consciousness, or a sudden severe headache may indicate an emergency such as stroke and require immediate medical attention.
Disclaimer
This article is provided by Aricares Alliance for educational and informational purposes only. It is not intended to diagnose, treat, or prevent NPH or any other medical condition and should not replace individualized medical advice. Anyone experiencing progressive neurological or functional changes should consult an appropriately qualified healthcare professional. Sudden neurological symptoms require emergency medical evaluation.
Additional Resources
1. NIH/NINDS
2. Hydrocephalus Association
References
Luciano MG, et al. A Randomized Trial of Shunting for Idiopathic Normal-Pressure Hydrocephalus. New England Journal of Medicine. 2025;393:2198–2209.
Expert Consensus for the Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus (2026 Edition). Zhonghua Yi Xue Za Zhi. 2026;106(27):2795–2818.
Mayo Clinic. Hydrocephalus: Symptoms and Causes. Updated March 17, 2026.
Mayo Clinic. Hydrocephalus: Diagnosis and Treatment. Updated March 17, 2026.
Halperin JJ, et al. Practice Guideline: Idiopathic Normal Pressure Hydrocephalus: Response to Shunting and Predictors of Response. Neurology. 2015;85:2063–2071.
Cochrane Database of Systematic Reviews. Shunting for Idiopathic Normal Pressure Hydrocephalus. 2024.
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