Normal Pressure Hydrocephalus

An older adult who begins taking short, hesitant steps, has difficulty turning, and develops urinary urgency may be showing the gait-first pattern of normal pressure hydrocephalus (NPH), especially when thinking becomes slowed rather than primarily amnestic. The feet may seem “stuck to the floor,” and falls can occur before the cognitive or bladder symptoms are severe. NPH is a clinical syndrome of enlarged ventricles with normal or intermittently elevated CSF pressure. It may be idiopathic or follow conditions such as subarachnoid haemorrhage, meningitis, or head trauma. The term “normal pressure” is therefore a useful exam label, not reassurance that intracranial dynamics are normal. Recognition matters because selected patients may improve after CSF diversion, with gait generally showing the clearest benefit. The diagnosis is not made from one symptom, one pressure measurement, or ventricular enlargement alone. The clinician integrates the symptom pattern, brain imaging, exclusion of competing causes, and—when appropriate—objective change after CSF drainage.