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NPH Treatment Delivers Life-Changing Care to Older Adults


Gait apraxia, cognitive decline and urinary incontinence in older adults are not necessarily signs of aging. These symptoms cause a rapid decline in quality of life and may be the result of an underdiagnosed—and treatable—condition known as normal pressure hydrocephalus or NPH.

This condition happens when cerebrospinal fluid (CSF) accumulates, causing ventricles to enlarge and press against the brain. Inserting a shunt to drain the excess fluid can improve symptoms in a profound way. Yet relief eludes many patients because symptoms are often misdiagnosed as Alzheimer’s disease or Parkinson’s disease.

Normal Pressure Hydrocephalus (NPH) Care

According to the neurosurgeon Gregory J. Zipfel, MD, “Effective treatment starts by going to a center of care with a formal evaluation process and multidisciplinary team.” This approach is a cornerstone of NPH care at the Washington University and Barnes-Jewish Neurology & Neurosurgery Center in St. Louis—the only care of its kind in the region.  

Neurosurgeon, Dr. Zipfel, and neurologist, Mwiza Ushe, MA, MD, lead the team. We use a rigorous process to accurately diagnose NPH and identify patients who are most likely to benefit from shunt therapy. 

Timely Access to NPH Care and Treatment

Dr. Ushe and our team of neurosurgeons perform a comprehensive evaluation in collaboration with neuroradiologists, neuropsychologists and rehabilitative therapists. Clinicians work together to coordinate their findings. Then they provide a plan to help patients rapidly progress toward treatment.

“We offer a streamlined approach with a single point of entry,” says Dr. Zipfel. “Patients come to us with a referral to either neurology or neurosurgery, and we coordinate every step of their care. Patients can receive a comprehensive evaluation and undergo shunt surgery in as little as one week.”

Multidisciplinary NPH Evaluation and Treatment

NPH evaluations include:

  • A neurologic examination to measure brain functioning
  • Magnetic resonance imaging (MRI) to investigate CSF flow and brain anatomy 
  • A neuropsychology evaluation to assess cognitive difficulties 
  • Gait analysis to quantify challenges with balance and walking

A confirmed diagnosis of NPH is not the sole indicator of whether shunting is the appropriate treatment pathway. Shunt therapy is not effective in patients with additional problems such as cerebral amyloid angiopathy and microhemorrhages. 

To help patients receive medically appropriate care, Washington University’s NPH team observes the potential effects of shunting with the help of a lumbar drain trial. This inpatient test draws CSF samples over a period of 48 to 72 hours and is safer than traditional lumbar puncture tests.

Shunt Therapy and a Return to Normal Daily Life

Patients who respond well to the lumbar drain trial, especially those who experience improvements in gait, undergo surgery to implant a shunt. Washington University uses the latest programmable shunts, which allow neurologists to make adjustments in the clinic setting using a magnet.

Patients often start feeling better within days. Inpatient and outpatient rehabilitative therapy helps optimize outcomes. Patients often regain their independence and resume activities within a few months.

Advancing NPH Care Through Research

True to our mission of advancing human health through the best clinical care, Washington University Physicians are laying the groundwork for additional NPH care breakthroughs with research. Find out more about our Office of Neuroscience Research.

Our research interests include:

  • Standardizing clinical decision-making:We are establishing indicators to reliably predict which patients will benefit from shunt therapy by compiling and analyzing:
    • Neuroimaging data to identify radiographic markers
    • CSF samples to identify biomarkers 
  • Developing protocols for comorbid conditions:The NPH team is working with Washington University’s world-renowned Knight Alzheimer's Disease Research Center(ADRC) to establish protocols for evaluating and treating Alzheimer’s patients who are also experiencing the symptoms of NPH. 

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