Gait disorder in older adults: Is it NPH? - ResearchGate

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Gait disorder in older adults: Is it NPH?
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Gait disorder
in older adults:
Is it
NPH?
Abstract: In normal pressure hydrocephalus (NPH), there is enlargement of the brain’s
ventricular system due to an excess of cerebrospinal fluid. The triad of symptoms in NPH are
gait disorder, cognitive impairment, and urinary continence problems. NPs need to consider
the possibility of NPH in older adults with a hypokinetic gait.
A
By Cira Fraser, PhD, RN, ACNS-BC, and Sharon W. Stark, PhD, RN, APRN-BC
n older gentleman enters a coffee shop on the upper
west side of Manhattan. He can barely lift his
feet as he walks and has a wide gait with little knee
flexion. His gait is slow and he is inattentive. He stops for a
minute or so and gazes around the shop, down at the floor,
and then back to the door he just entered. His posture is not
straight. His body has a slight lean backward as he walks. He
continues to walk, and as he turns his body slightly to the left,
he almost loses his balance. The man’s arms look relaxed and
they swing in a typical way while moving. It takes him about
10 minutes to walk from the door he entered to the counter
of the coffee shop about 30 feet away. Once at the counter, he
appears unsure of what to order and then orders his usual
hazelnut coffee. Although his feet appear as if they are stuck
to the floor as he tries to walk, he manages to make it safely
to a table nearby. He sits to enjoy his coffee over the next 30
minutes. Once done, it takes the gentleman about 10 minutes
to exit the door and very slowly walk to his apartment, which
is two doors down from the coffee shop.
The gentleman in the case study has the distinctive gait
and other common signs and symptoms of possible normal
pressure hydrocephalus (NPH) in older adults.
NPH is often the cause of hypokinetic gait in older
adults. 1 The triad of symptoms most commonly associated
with NPH are a distinctive gait, cognitive impairment, and
urinary continence problems. 2 (See NPH triad of symptoms.)
Although the exact incidence of NPH is unknown, it is
estimated that approximately 375,000 people in the United
Key words: cognitive impairment, gait disorder, hypokinetic gait, normal pressure hydrocephalus
14 The Nurse Practitioner • Vol. 36, No. 3 www.tnpj.com
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Gait disorder in older adults: Is it NPH?
States, or 5% of the population may have NPH. The numbers
are expected to increase due to extended longevity. 3 In
2005, an international study group developed and reported
comprehensive guidelines for NPH. 3
In NPH, there is an enlargement of the brain’s ventricular
system due to an excess of cerebrospinal fluid (CSF) thought to
be related to decreased reabsorption of CSF by the arachnoid
villi surrounding the exterior of the brain (see Normal flow of
CSF). As the ventricles slowly enlarge from the accumulation
of CSF, tissue compliance increases and further ventricular
enlargement results. 4 Subsequently, increased intracranial
pressure is transient as the ventricles are able to accomodate
more CSF. As the ventricles continue to enlarge, edema, and
permanent changes in the shape of the ventricles may cause
periventricular and vascular damage. Additionally, compression
of brain parenchyma and vessels and the accumulation of
toxins due to slow refreshment of CSF and decreased clearance
of metabolites increases CSF-flow obstruction and progressive
ventriculomegaly. Signs and symptoms of NPH occur as
various areas of the brain are compressed. 4
The etiology of NPH is unclear. Chrysikopoulos 4 states
the perplexing feature of NPH is the progressive enlargement
of the ventricles in the absence of mechanical obstruction
of CSF, along with a normal mean intraventricular and
mean intracranial pressure. NPH can be either idiopathic
or secondary to head trauma, meningitis, or subarachnoid
bleed. The author hypothesized that in NPH, alterations
in the normal systolic-diastolic cycle of blood flow in the
brain will disrupt the normal propulsion of CSF. Abnormal
ventricular systole in the brain is thought to be caused by
stiff and narrowed arteries due to atherosclerosis and hypertension.
4 Poor circulation of CSF is proposed to result in
toxic/osmotic effects that may include cellular and axonal
dehydration. Chrysikopoulos 4 states there is evidence linking
NPH to diseases of the cerebral arteries.
Krauss et al 5 investigated vascular risk factors and arteriosclerotic
disease in NPH in older adults. The sample
included 65 participants who ranged in age from 50 to 87
with a mean age of 70.8 years. Forty-six percent were men,
and 54% were women. Variables examined included systemic
arterial hypertension, diabetes mellitus, smoking, hyperlipidemia,
hypercholesterolemia, obesity, and cardiac, cerebrovascular,
and other arteriosclerotic disease. A highly significant
association was found between NPH and systemic arterial
hypertension. A positive relationship was also found between
the severity of clinical symptoms of NPH and the presence
of systemic arterial hypertension, especially for severe gait
disturbance. Diabetes mellitus was found to be associated
with NPH; however, when the variables were examined using
logistic regression, only systemic arterial hypertension was
found to have a significant association with NPH.
Since NPH typically is most common in individuals in
their sixth and seventh decades, its characteristic triad of
symptoms can be easily mistaken for other conditions attributed
to aging, thereby delaying its diagnosis. 6 The diagnosis
of NPH does not require the presence of all three symptoms.
The first symptom to be exhibited is usually a change in gait,
while cognitive and urinary changes occur later. In fact, if
cognitive impairment occurs before disturbances in gait then
NPH is probably not present. 7,8
■ Distinctive gait of NPH
NPH is a diagnostic challenge with gait impairment as the
cardinal sign. 9 Gait disturbance is an early sign of NPH.
The distinctive gait is described as having reduced velocity,
diminished stride length, broad-based, and reduced
foot-to-floor clearance. There is an increased foot angle,
with the feet rotated outward. 10 Step height is greatly
diminished, giving the appearance that the person’s feet
are stuck to the floor. 1
Older adults with NPH tend to hesitate when initiating
ambulation or turning. They are unsteady and lose their
balance easily. NPH is distinguished from a similar gait in
Parkinson disease by the preservation of reciprocal arm
swing when walking. 11 Also, a levodopa challenge may be
done to differentiate between NPH and Parkinson disease.
Patients with NPH will not respond to levadopa. 12
Those with NPH struggle to rise from a seated position
and have difficulty initiating the first steps in walking. Climbing
stairs may be problematic, as their step height is diminished
and their stride length is shortened. Some patients may
only present with a history of frequent falls. 7,13 Individuals
with NPH may also appear to lean backwards slightly when
standing and ambulating and have a larger sway area than
healthy individuals. 14
■ Cognitive impairment
Cognitive impairments in NPH can range from minimally
detected to profoundly severe. Over time, cognitive impairments
may become more generalized and more difficult to
manage. 2 In NPH, cognitive impairment typically includes
inattentiveness, lack of spontaneity, and latency in recall. The
processing of information tends to be slow. A fact recalled
by a person with NPH is most often accurate. The answers
provided to questions are frequently correct. The dementia
from NPH is distinct from that noted in a person with Alzheimer
disease (AD). The individual with NPH should not
have difficulty with word formation or carrying out simple
tasks that do not require concentration. 13
Differentiating between cortical and subcortical deficits
is key to distinguishing NPH from other cognitive
impairments and dementias. If cognitive impairment is
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Gait disorder in older adults: Is it NPH?
NPH triad of symptoms 1,2,10,11,13
Gait disturbance
• Appears before cognitive or urinary symptoms
• Reduced velocity
• Diminished stride length
• Broad based
• Reduced floor-to-foot clearance
• Diminished step height
• Increased foot angle
• Feet rotated outward
• Feet appear to be stuck to the floor
• Hesitates when initiating ambulation
• Hesitates when turning
• Unsteady
• Loses balance easily
• Normal reciprocal arm swing when walking
Cognitive impairment
• Inattentiveness
• Lack of spontaneity
• Latency in recall
• Slowed processing of information
• Fact recall most often accurate
• Answers provided to questions frequently correct
• No difficulty with word formation
• Can carry out simple tasks
Urinary continence problems
• Perception of pressing need to void
• Urinary frequency more than six voiding episodes in
12 hours
• Nocturia more than twice in an average night
• Episodic incontinence
• Persistent incontinence (later sign)
the predominant symptom, it is not likely that NPH is
present. 7,8 Symptoms such as memory loss and aphasia are
the result of a dysfunction in the cortex and are not likely
to be associated with NPH. 7,13 AD in conjunction with
NPH is common among the elderly with hypertension. 15
■ Urinary continence problems
Urinary continence issues in NPH primarily involve urinary
urgency and frequency. These early symptoms can
later progress to urinary incontinence. Urinary continence
problems may include episodic or persistent urinary incontinence
and frequent perception of a pressing need to
void. Urinary frequency in NPH is typically more than six
voiding episodes in 12 hours despite limited fluid intake.
Also nocturia more than twice in an average night is common
in NPH. 2 Underlying medical problems, such as benign
prostatic hyperplasia, bladder cancer, neurogenic bladder,
and cystitis should be considered before attributing urinary
symptoms to NPH. Also the use of diuretics, anticholenergics,
and other medications may be the cause of urinary
urgency and frequency. 7,13
■ Additional problems associated with NPH
In addition to the triad of symptoms most often associated
with NPH, there are a number of additional problems
that may occur in NPH. Affected neuropsychologic
and cognitive functions may include, but are not limited
to, short-term memory, numeracy (math skills needed to
cope with everyday life), abstract thought, concentration,
dexterity, and writing skills. In addition, behavioral and
psychiatric changes observed in NPH may include awakening
fluctuations, fantastic confabulation, reduced alertness,
easily fatigued, apathy, bipolar disorder, depression, and
obsessive-compulsive disorder. 10
■ Health history and assessment
A thorough health history and physical exam are essential to
efficiently and accurately diagnose NPH so that treatment
can begin quickly. Delayed diagnosis and treatment have
negative effects on the patient’s prognosis. 6,16
A thorough patient history of symptom onset and
progression, medical history of both the patient and the
family, and past and present medications are important
components of the evaluation. 8,16,17 A detailed gait history
should be obtained from the patient and family about the
onset of walking problems and whether the gait problems
had a sudden onset or a gradual decline. A gradual decline
is consistent with NPH. 7 Many other diseases present with
similar symptoms as NPH and must be considered in the
differential diagnoses. Headache, visual disturbances, and
nausea may be present as a result of the increased intracranial
pressure. 8,16,17
Gait should be assessed for reduced velocity, diminished
stride length, broad-based stance, and reduced foot-to-floor
clearance. Also assess for an increased foot angle, with the
feet rotated outward. 10 A greatly diminished step height gives
the appearance that the person’s feet are stuck to the floor. 1
Hesitation when the individual initiates ambulation and when
turning, unsteadiness, and loss of balance are consistent with
NPH. 11 The gait of NPH is distinguished from that of Parkinson
through observation of posturing and arm swing. 11,14
A cognitive evaluation will typically reveal mild cognitive
impairments presenting as inattentiveness, lack of
spontaneity, and latency in recall. 13 Although the processing
of information tends to be slow, memory recall is accurate
and answers to questions are mostly correct. Unlike those
with Alzheimer disease, individuals with NPH can carry
out simple tasks and do not experience difficulty with word
formation and understanding. 7,13 Cognitive evaluation
using standardized neuropsychologic evaluation tools are
useful in identifying cognitive impairments and dementias. 6
Urinary continence issues are identified during history
taking and can be further evaluated through urodynamic
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Gait disorder in older adults: Is it NPH?
evaluation. It is a late sign in NPH
patients and patients will initially
relate that they experience urinary
urgency, frequency, and nocturia.
Other underlying medical
issues and/medications need to
be ruled out before attributing
incontinence to NPH. 2,7,13
■ Diagnostic tests
Standardized neuropsychologic
tests are useful for identifying
cognitive impairment and to distinquish
subcortical from cortical
dementias. 6 There are several
screening instruments useful to
determine cognitive deficits in
those with NPH. The Mini-Cog
and Short Portable Mental Status
Questionnaire are useful to
identify cognitive impairment,
and the Folstein Mini-Mental
State Examination can identify
the severity of cognitive impairment.
Visuospatial skills and executive
function are assessed with
Normal flow of CSF
the Clock Drawing Test. 7 Finally, the Geriatric Depression
Scale identifies depression that may present as cognitive
deficiencies. These tests are helpful in determining not only
whether a person is a candidate for shunting, but also how
successful the shunting is when completed. 6,7
Cystoscopic and urodynamic testing are useful in determining
stress and/or overflow incontinence, as well as other
causes of urinary symptoms such as benign prostatic hyperplasia,
bladder cancer, neurogenic bladder, and cystitis. 18,19 A
urodynamic evaluation will show hyperactivity of the bladder. 8
Radiographic imaging is used to support the diagnosis
of NPH, as well as ruling out other causes of symptom
presentation. In NPH, computed tomography (CT) scans
reveal ventricular enlargement. Magnetic resonance imaging
(MRI) results reveal significantly increased CSF in the
ventricles of the brain. There is also decreased CSF in the
medial subarachnoid spaces when those with NPH are compared
with those with vascular dementia or with Alzheimer
disease. 20 The following imaging criteria may be helpful to
ascertain ideal candidates for shunt placement: ventriculomegaly,
improvement of symptoms after CSF drainage,
normal-sized or occluded sylvian fissures and cortical sulci,
absent or moderate white matter lesions. 12
In NPH, single-photon emission computed tomography
(SPECT) will reveal diminished cerebral blood flow that is
The illustration below represents the normal flow of CSF from its formation from
blood in the choroid plexuses until its return to the blood in the superior sagittal sinus.
Subarachnoid
space
Superior
sagittal
sinus
Lateral ventricle
Interventricular
foramen
Pons
Arachnoid villi
Choroidal plexus
fourth ventricle
Foramen of Magendie
Source: Porth CM, Matfin, G. Pathophysiology Concepts of Altered Health States. 8th ed. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
Choroidal
plexus third
ventricle
common in NPH. Radionuclide cisternogram differentiates
communicating from obstructive hydrocephalus and determines
CSF flow after radioactive material is infused into the
CSF and tracer activity identifies CSF outflow obstructions. 6,17,19
Tests that involve lumbar puncture show the most potential
in diagnosing NPH and also identify appropriate
candidates for shunt placement. A lumbar puncture reveals
normal CSF pressure and normal levels of protein, glucose,
and cell counts. 15 McGirt et al 21 conducted a 10-year retrospective
study and found that NPH can be diagnosed accurately
using a 3-day CSF drainage trial via spinal catheter or
CSF pressure monitoring. The withdrawal of 50 mL of CSF
is also used for the prognostic evaluation. There is varying
specificity and sensitivity evident in the medical literature.
The removal of CSF reveals transient improvement in gait
and cognition. 22 A CSF infusion test involves infusion of
fluid into the lumbar subarachnoid space to determine a
patient’s capacity to absorb CSF (CSF absorptive capacity)
and shows improvement in symptoms. Symptom improvement
in any of these tests indicates that ventricular shunting
is an appropriate intervention (See NPH diagnostic tests). 15
■ Treatments
NPH is often treated with a ventriculoperitoneal shunt (VP
Shunt) to divert excess CSF away from the brain. A ventricu-
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Gait disorder in older adults: Is it NPH?
NPH diagnostic tests
Neurologic
• CT scan reveals ventricular enlargement 20
• MRI reveals increased CSF in the ventricles 12
6, 17, 19
• SPECT reveals diminished cerebral blood flow
• Radionuclide cisternogram with radioactive tracer
differentiates communicating from obstructive hydrocephalus,
CSF flow, and outflow obstructions
6, 17, 19
• Lumbar puncture reveals CSF pressure, protein,
glucose, and cell counts 17
• 3-day CSF drainage trial via spinal catheter or CSF
pressure monitoring reveals transient improvement in
21, 22
gait and cognition
• CSF infusion test determines CSF absorptive capacity
and improvement in symptoms 15
Cognitive
• The Mini-Cog evaluates level of cognitive ability 6, 7
• Short Portable Mental Status Questionnaire evaluates
level of cognitive ability 6, 7
• Folstein Mini-Mental State Examination evaluates level
of cognitive ability 7
• Clock Drawing Test identifies visuospatial skills and
executive function 7
• Geriatric Depression Scale identifies depression 6, 7
Urologic
• Cystoscopic and urodynamic testing determines
causes of urinary symptoms 18,19
• A urodynamic evaluation identifies bladder hyperactivity 8
lar catheter is inserted into the brain, and CSF exits through
a valve and is connected to a catheter that is tunneled under
the skin down to the peritoneal cavity. 6,8,19
Following the insertion of a VP shunt, care should include
positioning the individual supine 12 to 24 hours
and elevating the head of the bed gradually, following the
neurosurgeon’s protocol. This gradual elevation helps to
prevent overshunting of CSF. 23 Overshunting can result in
collapse of the ventricles of the brain and cause bleeding.
Acute intracranial hemorrhage is the primary risk following
the insertion of a VP shunt and tends to be underreported. 23
A new laparoscopic technique is being used by some neurosurgeons
to insert the peritoneal portion of the VP shunt
catheter. This new approach has a number of benefits when
compared with the traditional approach. The length of time
for surgery is shorter, less trauma for the patient, and fewer
complications, especially shunt obstruction. 24
Individuals with a shorter duration of NPH symptoms
and the presence of gait impairment are likely to improve following
the insertion of a VP shunt. 21 In a review of the literature
back to 1966, Klinge, Marmarou, Bergsneider, Relkin, and
Black 25 found that gait improvement following the insertion
of a VP shunt ranged from 30% to 95%. Improvement is not
sudden, but occurs slowly over the weeks and months that
follow the insertion of the shunt. Improvement will persist
as long as the shunt is working properly. 7
Unlike other dementias, cognitive impairment in NPH
can, in some cases, be reversed. Patients with multiple medical
problems should be thoroughly evaluated so that successful
reversal of NPH is not delayed. Surgical shunting provides
the most benefit when performed early in the disease process.
Shprecher, Schwalb, and Kurlan 15 reported that AD, in
combination with NPH, is common among the elderly with
hypertension. Although shunting may improve gait dysfunction,
severe dementia does not improve. Therefore, shunting
in patients with severe dementia is discouraged.
■ Complications
Shunt complication are estimated to be as follows: intracerebral
hematoma 3%, infection 6%, seizure activity 3% to
11%, subdural hematoma 2% to 17%, and shunt malfunction
20%. 23 Malfunction includes obstruction and overand
underdrainage of CSF. Shunt obstruction is the most
common complication and should be suspected when there
is no improvement in symptoms or if symptoms recur. 8,12
■ Implications for practice
NPs and other healthcare professionals are likely to recognize
the symptoms of NPH in older adults and make a difference
in the quality of life of older adults and their family members.
Fraser and Fraser 26 state that all healthcare professionals need
to become familiar with the gait in NPH. The gait is the cardinal
sign of NPH. The ability to recognize the NPH gait can
be sharpened by observing those recently diagnosed, those
who just had a shunt inserted, or by reviewing a video of the
distinctive gait. 27 When a patient presents with the distinctive
gait of NPH alone, or with cognitive impairment and/or
urinary continence problems, a comprehensive history and
physical exam is indicated to differentiate NPH from other
diseases. Family-focused care is essential in obtaining an accurate
history of the patient’s symptoms, behaviors, walking
characteristics and pattern over time, history of falls, and
activities of daily living. Family-focused care is also essential
during the ongoing care of the older adult with NPH. 26
Evaluation of gait, changes in cognition over time and
present cognitive state, and present urinary symptoms and
progression of symptoms provide important indicators
for diagnosing NPH. If NPH is suspected, imaging studies
should be performed to identify ventriculomegaly. If ventriculomegaly
is confirmed, prompt referral for neurologic
or neurosurgical evaluation is essential.
Following shunt placement, improvement may develop
over weeks and months. 7 Education provides the knowl-
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Gait disorder in older adults: Is it NPH?
NPH websites
Life NPH: Hope for People with Normal Pressure
Hydrocephalus
http://www.lifenph.com/
Chicago Institute of Neurosurgery and Neuroresearch
CINN NPH Program
http://www.cinn.org/other/nph-home.html
Medtronic: Normal Pressure Hydrocephalus
http://www.medtronic.com/hydrocephalus/nph/index.html
National Institute of Neurological Disorders and Stroke
Normal Pressure Hydrocephalus Information Page
http://www.ninds.nih.gov/disorders/normal_pressure_
hydrocephalus/normal_pressure_hydrocephalus.htm
Hydrocephalus Association
http://www.hydroassoc.org/tag/normal-pressurehydrocephalus/
edge necessary for patients and families to have realistic
expectations and recognize shunt complications early. They
should be taught to be attentive to the return of preoperative
symptoms, headaches, visual disturbances, fatigue, sleep
difficulties, personality changes, and paralysis and reporting
them promptly to the neurosurgeon. 6,7,19 The patient and
family need to be aware that headache that is relieved when
the person reclines may possibly be due to overshunting and
should be reported promptly to the neurosurgeon. A CT
scan may reveal the presence of collapsed ventricles. Infection
near the implanted shunt itself may result in meningitis
or CSF infection that may result in peritonitis. The patient
and family should be taught the general signs and symptoms
of infection, as well as those for meningitis and peritonitis.
Any problems or concerns should be reported immediately
to the neurosurgeon. Also, the patient should receive regular
follow-up care with the neurosurgeon. 25
As older adults live longer, stress and burden will increase
among families and individuals who take on the role
of family caregiver for the older adult. As such burden and
stress will be experienced in increasing levels, NPs can assist
caregivers. Therefore, NPs must advocate for patients’
families and caregivers by referring them for support services
through local support groups, social services, and NPH organizations.
Support and knowledge can improve the quality
of life for both those affected by NPH and those responsible
for their care. (See NPH websites and Case study of a delayed
diagnosis and recovery from NPH).
Lastly, it is important that patients and families be informed
about the treatment options and prognoses when
deciding on shunting intervention. NPs have an opportunity
to provide unbiased information about NPH signs,
symptoms, diagnosis, treatment, surgical risks, benefits, and
Case study of a delayed diagnosis and
recovery from NPH 26
SF was 74 when his daughter realized that he was having
some new problems. SF had a 10-year history of type 2
diabetes and hypertension, but started to have a problem
with his walking and frequent falls. His gait was extremely
slow and his feet looked as though they were glued to the
floor. His stance was wide-based with little knee flexion.
SF tended to lean backward a bit as he stood in place or
walked. Because he had inattentiveness and the slow gait,
it took him about 10 minutes to walk from one room to
another in his apartment. He seemed forge tful and slower
in thought, yet he was able to carry out simple tasks
independently. SF had been very good with his math for
most of his life and started to have difficulty managing his
checkbook. He was getting forgetful and had difficulty taking
his medication properly. He had urgency, frequency,
nocturia, and bladder incontinence at least once a day. His
daughter was concerned about his health and took him to
his long-time primary care provider every 3 months and
also to a geriatric specialist. Both stated there was nothing
that could be done about his recent health issues and that
his dementia would gradually get worse. This went on for
4 years, but he only had mild cognitive decline during this
time and continued problems with walking, occasional
falls, and the urinary symptoms.
SF’s daughter felt that something could be done for
her father and arranged for him to be evaluated by a
multidisciplinary team. The diagnosis of NPH was made
when he was 78 years old. He had a neurologic assessment;
a CT scan revealed dilated lateral ventricles in the
brain. The withdrawal of 50 mL CSF via lumbar puncture
resulted in transient improvement in his gait for about
18 hours. The ventriculoperitoneal shunt insertion into
the lateral ventricle on the nondominant side of his brain
resulted in gradual improvement over a 1-year period.
During the first month, his social interactions improved
and he was more attentive. He walked with a quad cane
to avoid falling and received physical therapy three
times a week at home for 1 month.
At 3 months, his gait was steady and he could walk
slowly and safely in his apartment without a cane. At 6
months, his memory had improved. He was once again
able to calculate simple math problems and manage his
own checkbook. He walked at a normal pace without falling.
One year after surgery he was able to write better,
was more attentive, and had improved memory.
prognosis and to educate patients and families so they can
make educated decisions and best care for themselves and
their dependent elders.
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The authors have disclosed that they have no financial relationships related to
this article.
Cira Fraser is an associate professor and graduate faculty and Sharon W. Stark is
associate dean and graduate faculty at Marjorie K. Unterberg School of Nursing
and Health Studies, Monmouth University, West Long Branch, New Jersey, N.J.
DOI-10.1097/01.NPR.0000393969.13812.2e
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