Normal Pressure Hydrocephalus: A Often Missed Cause of Walking Problems and Falls

As a physiotherapist working with older adults, I often see people whose walking has gradually changed over time. Sometimes this is due to arthritis, weakness, or deconditioning. Occasionally, however, there may be another cause that is less well known but important to recognise: Normal Pressure Hydrocephalus (NPH).

NPH is a neurological condition that can affect walking, balance, bladder control and thinking. The key thing to know is that it is one of the few potentially reversible causes of walking problems and cognitive decline, particularly in older adults.

Understanding the signs can help people seek the right assessment and treatment earlier.

What is Normal Pressure Hydrocephalus?

Normal Pressure Hydrocephalus occurs when cerebrospinal fluid (CSF) – the fluid that surrounds and protects the brain and spinal cord – builds up in the brain’s ventricles (fluid-filled spaces).

This causes the ventricles to enlarge and place pressure on surrounding brain tissue. Despite this build-up of fluid, the overall pressure of the fluid often measures within the normal range, which is where the name comes from.

The condition most commonly affects people over the age of 60 and can develop gradually over months or years.

Sometimes there is an identifiable cause, such as:

• Previous brain injury

• Bleeding around the brain

• Infection

• Brain surgery

However, in many cases no clear cause is found, which is known as idiopathic NPH.

The Classic Symptoms

NPH is commonly described as a triad of symptoms, although not everyone develops all three.

1. Walking and Balance Problems

Walking changes are often the earliest and most noticeable sign.

People may experience:

• A slow, shuffling walk

• Difficulty lifting their feet

• A “magnetic” gait (feet feel stuck to the floor)

• Reduced step length

• Wide stance when walking

• Difficulty turning

• Increased falls

Many people describe feeling as though their feet will not move when they want them to, particularly when starting to walk or turning.

This can look similar to conditions such as Parkinson's disease, which is why NPH can sometimes be misdiagnosed initially.

2. Bladder Problems

Urinary symptoms often develop gradually and may include:

• Urinary urgency

• Increased frequency

• Difficulty reaching the toilet in time

• Urinary incontinence

These symptoms are sometimes mistakenly attributed purely to ageing.

3. Cognitive Changes

Cognitive symptoms are usually milder than those seen in conditions like Alzheimer's disease, but may include:

• Slower thinking

• Difficulty concentrating

• Reduced attention

• Reduced motivation

• Mild memory problems

Family members may notice the person becoming less engaged or slower to process information.

Why Walking Problems Are So Important

From a physiotherapy perspective, changes in walking are often the earliest clue that something neurological may be happening.

In NPH the walking pattern can have some distinctive features:

• Short, shuffling steps

• Difficulty initiating movement

• Reduced foot clearance

• Poor balance when turning

• Increasing reliance on furniture or walking aids

Because of this, people are often referred to physiotherapy for falls or reduced mobility before the diagnosis is made.

Increased Risk of Falls

People with NPH often have a significantly increased risk of falls.

This may be due to:

• Reduced step height and foot clearance

• Difficulty initiating movement

• Slower balance reactions

• Turning instability

• Reduced attention or dual-task ability

Falls may begin to occur inside the home, especially when turning, navigating tight spaces, or getting up quickly.

For clinicians assessing falls, a gradual change in walking over months combined with bladder symptoms or cognitive slowing should raise suspicion.

How is Normal Pressure Hydrocephalus Diagnosed?

Diagnosis usually involves a combination of clinical assessment and brain imaging.

Clinical Assessment

A specialist (often a neurologist or geriatrician) will assess:

• Walking pattern

• Balance

• Cognitive function

• Bladder symptoms

• Medical history

Physiotherapists are often involved in formal gait assessments before and after testing procedures.

Brain Imaging

A brain scan is essential, usually with:

• MRI scan

• or CT scan

These scans show enlarged brain ventricles, which suggests fluid accumulation.

Lumbar Puncture (Tap Test)

A common diagnostic test is a large-volume lumbar puncture, where some cerebrospinal fluid is removed from the lower spine.

This is sometimes called the “tap test.”

If walking improves after the fluid is removed, it strongly suggests the person may benefit from treatment.

Physiotherapists are often asked to assess walking before and after this procedure to measure any improvement.

Treatment for Normal Pressure Hydrocephalus

The main treatment is surgical.

Ventriculoperitoneal Shunt

Most people are treated with a Ventriculoperitoneal shunt.

This is a small tube placed in the brain that drains excess fluid into the abdomen, where it can be absorbed by the body.

The procedure aims to reduce pressure on the brain and improve symptoms.

Many patients experience significant improvement in walking, sometimes within days or weeks.

Bladder symptoms and cognitive changes may also improve, although walking tends to respond the best.

How Physiotherapy Can Help

Physiotherapy plays an important role both before and after diagnosis.

Before Diagnosis

Physiotherapists may help by:

• Identifying unusual walking patterns

• Assessing fall risk

• Noticing symptom combinations that may warrant further investigation

• Referring back to medical teams if concerns arise

After Treatment

Following shunt surgery, physiotherapy can help people:

• Relearn more normal walking patterns

• Improve balance

• Increase walking confidence

• Reduce falls risk

• Build strength and endurance

Rehabilitation may include:

• Gait retraining

• Balance exercises

• Strength work for the legs

• Functional practice (turning, stairs, transfers)

When Should Someone Seek Medical Advice?

It may be worth seeking medical advice if someone develops:

• A gradual change in walking pattern

• Frequent falls

• New bladder urgency or incontinence

• Slower thinking or reduced engagement

Particularly if these symptoms occur together.

Although NPH is not extremely common, it is important to recognise because it is one of the few neurological conditions where treatment can significantly improve symptoms.

Final Thoughts

Normal Pressure Hydrocephalus is sometimes called “the treatable dementia”, but in reality it is often the walking problems and falls that appear first.

For clinicians, carers and families, recognising the pattern of walking change, bladder symptoms and cognitive slowing can help ensure people receive appropriate assessment.

With the right treatment and rehabilitation, many people experience meaningful improvements in mobility, independence and quality of life.

About Physio@Home

If you're finding recovery from injury, surgery, illness, or a fall more challenging than expected, professional support in the comfort of your own home can make all the difference. At Physio At Home, we specialise in expert home visit physiotherapy across Mid Cornwall — including Truro, Falmouth, Penryn, Helston, Perranporth, Feock, St Agnes, and surrounding areas. Our HCPC-registered and experienced physiotherapists provide personalised assessments, tailored rehabilitation plans, mobility and balance training, and practical advice to help you regain strength, confidence, and independence without the hassle of travelling to a clinic. Ready to move better and feel better right where you live? Visit https://www.physioathome.uk/