Idiopathic Normal Pressure Hydrocephalus A Review

Nathan Hinkle — Wed, 16 Sep 2026 05:00:00 +0000

Date Added:

September 16, 2026

Journal/Publication:

JAMA

Publisher:

The American Medical Association

Publication Date:

September 14, 2026

URL:

E1-E14

Type:

Meta-analyses, Reviews, and Guidelines

CME Credits:

Format:

Article

DOI (1):

doi: 10.1001/jama.2026.15519

Keywords

Idiopathic Normal Pressure Hydrocephalus

neurology

cognitive assessment

MeSH

Hydrocephalus, Normal Pressure*

Cognitive Dysfunction* / therapy

urinary incontinence

RPR Commentary: A review of what we know about normal pressure hydrocephalus, and condition affecting up to 4% of older adults. James W. Mold, MPH.

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Abstract
Importance Idiopathic normal pressure hydrocephalus (iNPH) is a progressive neurological disorder characterized by cerebral ventricular enlargement that is typically associated with gait impairment and often urinary dysfunction and cognitive decline in older adults. iNPH prevalence is approximately 1% to 4% among individuals 65 years and older and 6% to 8% among those 80 years and older.

Observations iNPH is a multifactorial disorder involving interactions among cerebrospinal fluid (CSF) circulation, vascular dysfunction, and white matter injury. Unlike secondary NPH, iNPH occurs without a known antecedent event such as subarachnoid hemorrhage. Gait disturbance, including a broad-based, slow, shuffling gait and impaired turning, occurs in 85% to 95% of patients with iNPH and is often the earliest symptom. Urinary dysfunction occurs in approximately 75% to 90% of patients with iNPH and commonly includes urgency, nocturia, urge incontinence, or leakage. Cognitive impairment is reported in 60% to 80% of patients with iNPH, predominantly involving impaired attention, processing speed, working memory, verbal fluency, and cognitive flexibility. iNPH is diagnosed primarily based on characteristic clinical findings and neuroimaging (typically brain magnetic resonance imaging) demonstrating cerebral ventricular and subarachnoid space enlargement. Although necessary for diagnosis, these neuroimaging findings are not reliably associated with response to treatment. Early diagnosis of NPH is important because shorter symptom duration and less advanced disease are associated with more favorable outcomes. Patients being evaluated for iNPH should undergo large-volume lumbar puncture with removal of 30 to 50 mL of CSF to confirm the diagnosis and predict shunt responsiveness, measured as improvement in objective gait measures starting within hours after drainage. Extended lumbar drainage with removal of 200 to 300 mL of CSF over several days in an inpatient setting provides higher prognostic accuracy, and may be performed in patients with high clinical suspicion and a negative or equivocal clinical response to lumbar puncture. Treatment for iNPH is CSF diversion with shunt placement, most commonly performed with ventriculoperitoneal shunts, although ventriculoatrial and lumboperitoneal shunts may have similar efficacy. After shunting, approximately 75% to 80% of patients have gait velocity improvement; cognitive and urinary improvements occur in approximately 50% to 70%. Complications of shunts include overdrainage and underdrainage (10%-30%), presenting as postural headaches and subdural collections, and recurrence or worsening of iNPH symptoms, shunt malfunction (10%-20%), and shunt infections (<1%-2%).

Conclusions and Relevance iNPH affects approximately 1% to 4% of adults 65 years and older and is associated with gait impairment, cognitive decline, and urinary dysfunction. Symptoms improve in approximately 70% to 90% of patients with iNPH who undergo shunt surgery.

Author/s:

S. Farzad Maroufi, Sevil Yasar, Abhay Moghekar, Mark G. Luciano

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician

John Bayhi — Fri, 02 Aug 2019 18:51:18 +0000

Date Added:

August 9, 2019

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Mayo Foundation for Medical Education and Research

Publication Date:

August 1, 2019

Issue:

Volume:

Pages:

1582–1588

URL:

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2019.03.023

Keywords

MeSH

referral and consultation

A concise review of issues and counseling strategies relevant to older drivers. James W. Mold, MD, MPH

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Older drivers are putting more miles on the road during their “golden years” than generations prior. Many older adults have safe driving habits, but unique age-related changes increase the risk for crash-related morbidity and mortality. Generalists are poised to assess and guide older adults' driving fitness. Although there is no uniformly accepted tool for driving fitness, assessment of 5 key domains (cognition, vision, physical function, medical comorbidities, and medications) using valid tools can help clinicians stratify older drivers into low, intermediate, and high risk for unsafe driving. Clinicians can then make recommendations about fitness to drive and appropriate referrals for rehabilitation or alternative transportation resources to optimize mobility, independence, and quality of life for older adults.

Author/s:

Hill, Larisa J.N., Pignolo, Robert J., Tung, Ericka E.