Can a patient with Normal Pressure Hydrocephalus (NPH) experience increased frequency of dizziness and falls?

Can NPH Cause Dizziness and Falls with Increasing Frequency?

Yes, patients with Normal Pressure Hydrocephalus (NPH) commonly experience dizziness, unsteadiness, and falls, and these symptoms typically worsen over time as the disease progresses untreated. 1, 2

The Gait Disorder in NPH is the Primary Fall Risk

• Gait disturbance is the cardinal and earliest sign of NPH, characterized by a hypokinetic, magnetic, or "feet glued to the floor" appearance with shuffling, bradykinesia, and instability 3, 2
• This gait abnormality directly causes falls and creates a sensation of unsteadiness that patients may describe as "dizziness" rather than true spinning vertigo 2, 3
• The gait disorder in NPH presents as feeling unstable or off-balance without spinning, which represents dizziness rather than true vertigo 4

Progressive Nature and Fall Risk

• NPH follows a progressive course, with symptoms worsening over time if left untreated, ultimately leading to nursing care dependence in the vast majority of patients 1
• Recurrent falls are a common presenting complaint in NPH patients, with falls occurring frequently before diagnosis 2
• The combination of gait impairment, cognitive decline, and urinary incontinence (the classic triad) develops progressively, with gait typically appearing first 1, 3

Distinguishing NPH from Other Causes of Dizziness

Critical distinction: NPH causes persistent unsteadiness and imbalance, NOT brief episodes of spinning vertigo triggered by head position changes (which would suggest BPPV) 4, 5

• If the patient describes seconds-long spinning episodes triggered by rolling over in bed or looking up, consider BPPV instead 5, 4
• NPH patients experience continuous gait instability that worsens gradually over weeks to months, not episodic positional vertigo 1, 2
• The elderly are at particularly high risk, as 9% of elderly patients in geriatric clinics have undiagnosed BPPV (which could coexist with NPH), and three-fourths of BPPV patients had fallen within 3 months 5, 4

Diagnostic Approach When NPH is Suspected

Perform focused assessment for the NPH triad 1, 2:

• Gait evaluation: Look for magnetic, shuffling gait with poor balance
• Cognitive assessment: Screen for memory impairment and slowed processing
• Urinary symptoms: Ask about urgency, frequency, and incontinence

Obtain brain imaging 2, 6:

• CT or MRI showing disproportionate ventricular enlargement relative to brain atrophy
• This distinguishes NPH from age-related atrophy

Consider lumbar puncture with large-volume CSF tap 2, 3:

• Opening pressure should be normal (typically <18-20 mmHg)
• Transient improvement in gait after removing 30-50 mL of CSF strongly supports NPH diagnosis and predicts shunt responsiveness

Treatment Urgency

Early treatment with ventriculoperitoneal shunt placement is critical, as 70-90% of treated patients show clinical improvement, while untreated NPH progresses to severe disability 1, 3

• Shunt surgery improves gait, reduces falls, and may improve cognitive function and urinary symptoms 1, 3, 6
• Delayed diagnosis and treatment have significant quality-of-life and cost implications 1

Common Pitfall to Avoid

Do not dismiss progressive gait instability and falls in elderly patients as "normal aging" 1, 3. NPH remains unrecognized in approximately 80% of cases, yet it is one of the few reversible causes of dementia and gait disorder 1, 3. Three-quarters of NPH patients also have coexisting neurodegenerative disorders, which complicates diagnosis but does not preclude benefit from shunt surgery 1.