Let's learn everything about NPH disease (Normal Pressure Hydrocephalus) in a simple way.

Has your elderly mother, father, or grandmother suddenly found it difficult to walk? Is she walking very slowly? Or do you feel like your memory is gradually deteriorating? We often think of these as normal things that happen as we get older. But sometimes, these can be signs of a treatable condition. Similarly, NPH is a condition that many people mistake for dementia, but it is actually a treatable condition. Let's find out more about it today.

Simply put, what is NPH?

The full meaning of NPH is Normal Pressure Hydrocephalus. In Sinhala, it means "normal pressure hydrocephalus". But it's easier to understand than that word when you know that this is something that happens to the brain.

Simply put, NPH is a condition in which the fluid in and around our brain (we medically call it Cerebrospinal Fluid - CSF) builds up and interferes with brain function. This fluid, called CSF, nourishes our brain and helps remove waste products from the brain. It is also this fluid that protects the brain from being jostled around inside the skull and causing injuries.

The average adult brain contains about 150 milliliters of this fluid. Our bodies are constantly making this fluid, circulating it, and reabsorbing old fluid. As long as this cycle is happening properly, there is no problem.

But in the case of NPH, for some reason, the reabsorption or circulation of this fluid is impaired. Then, this fluid gradually begins to accumulate in the ventricles inside the brain. Because this happens very often, the pressure inside the skull does not suddenly increase significantly. That is why it is called "Normal Pressure". But over time, this accumulated fluid begins to squeeze the brain tissue and damage it. That is when the symptoms of NPH appear.

Who is most likely to develop this NPH condition?

NPH is a disease that most commonly affects people over the age of 65. The risk of developing this disease increases with age. The average age of onset is around 70 years.

This does not depend on things like race, religion, or gender. Aging is the main risk factor. According to statistics, 0.2% of people between the ages of 70 and 80 and 5.9% of people over the age of 80 have this disease. That means more than 8 million people worldwide suffer from this disease.

What are the main symptoms of NPH? "Hakim's Triad"

There are 3 main symptoms of NPH. These appear gradually over a period of 3 to 6 months. Doctors call these three main symptoms "Hakim's Triad." Between 50% and 75% of NPH patients experience all three symptoms together.

Let's see what these three characteristics are.

Why does this NPH develop? What are the causes?

There are two main types of NPH, depending on the causes.

1. Primary (Idiopathic) NPH

This is the most common type. About half of all patients have this type. "Idiopathic" means that the exact cause is unknown . It is currently believed to be caused by changes in the circulation and absorption of CSF fluid in the brain as we age.

2. Secondary NPH

This happens because of another medical condition or accident. That is, there is another reason that is interfering with the flow of CSF fluid in the brain. Some of these reasons include:

• Traumatic Brain Injuries
• Brain Tumors
• Stroke
• Intracranial Hemorrhage
• Brain Aneurysm
• Brain infections such as meningitis
• Brain surgery

How does a doctor accurately diagnose NPH?

Diagnosing NPH can be difficult because its symptoms are very similar to dementia conditions like Alzheimer's disease. Sometimes, NPH can also be accompanied by Alzheimer's disease.

A doctor uses several tests to diagnose this disease.

• Physical and neurological examination: The doctor will check your gait, balance, reflexes, and muscle strength.
• Asking about symptoms and medical history: Ask your family members about how these symptoms started and how long they have been present.
• Brain scan: This is the most important test. An MRI scan (Magnetic Resonance Imaging) can clearly see if the ventricles, where CSF fluid accumulates, are enlarged. Sometimes a CT scan (Computed Tomography) is also done to rule out other conditions.
• Spinal Tap / Lumbar Puncture: This is also a very important test. Here, a small needle is inserted into the spinal cord and a sample of CSF fluid is taken. This can be used to check for other infections. Also, most importantly, it is important to see if the patient's symptoms, such as difficulty walking, temporarily improve after removing some of the extra CSF fluid. If it does, it is a strong indication that NPH is present.

Is there a treatment for this? Can it be cured?

Yes! This is the good news about NPH. Although it may look like dementia, NPH is often a treatable disease. Medications are not very effective. The main and most effective treatment is surgery.

This surgery involves connecting a small tube-like device called a shunt to the brain.

• Think of this as a pipe that lets out extra water.
• One end of this shunt is connected to a chamber in the brain where CSF fluid collects.
• The other end is inserted under the skin into the abdominal cavity (stomach) or chest.
• The extra CSF fluid that accumulates in the brain then travels down this tube and empties into a place like the abdominal cavity, where the body can reabsorb the fluid.

After this surgery, patients' symptoms begin to improve dramatically within a few hours or days. This results in very good results, especially for difficulty walking.

In the case of secondary NPH, the disease that caused the NPH (e.g., a brain tumor) is treated first.

What complications can occur after treatment?

Although shunt surgery is generally safe, like any surgery, there are some risks.

• Infection.
• The shunt is blocked or malfunctioning.
• The shunt is located at the verr.
• Excessive CSF fluid draining from the brain (this can cause symptoms such as headaches).

If something like this happens, it can be identified and treated quickly. Therefore, it is very important to follow the doctor's instructions exactly after surgery and to go to the clinics on the scheduled dates.

What can you expect when living with NPH?

The outcome of NPH often depends on how quickly the disease is diagnosed and treated . The later treatment is given, the more likely it is that the brain damage will be permanent.

Since the patient may not be aware of their symptoms, family and loved ones have a big responsibility in this. If you notice these symptoms in your loved one, it is very important to take them to see a doctor, rather than assuming that it is a normal part of aging.

Here are the chances of symptoms resolving after treatment:

• Difficulty walking: About 85% of patients recover.
• Urinary incontinence: About 80% of patients recover.
• Thinking and memory impairment: About 80% of patients recover.

Let's look at the factors that affect the outcome of NPH disease in the table below.

When should I see a doctor? What are the times to go to the ETU?

If someone in your family has a shunt, you should be especially aware of certain symptoms. These could be signs of a problem with the shunt or an infection.

• Severe headache: If the headache gets worse, especially when sitting or standing up, this could be a sign that the drainage from the shunt is either reduced or increased.
• Fever or chills: This could be a sign of an infection after surgery. Never ignore these types of infections as they can spread quickly.
• Stiff neck.
• Pain in the chest or stomach area where the shunt tube passes.
• Reappearance of old NPH symptoms (difficulty walking, urinary problems).

NPH, Normal Pressure Hydrocephalus, Watery Head, Dementia, Memory Loss, Walking Difficulty, Elderly Health