Is normal pressure hydrocephalus curable?

It is one of the few potentially treatable and sometimes reversible causes of dementia-like symptoms. A shunt does not cure the underlying tendency, but in well-selected patients it can substantially improve symptoms — walking most reliably.

Why is NPH mistaken for dementia or Parkinson’s?

Because the memory changes and slow, shuffling walk overlap with Alzheimer’s and Parkinson’s disease, NPH is often missed or diagnosed late. Brain imaging plus a CSF tap test help distinguish it.

What is the "tap test" for NPH?

A lumbar puncture that removes a larger volume of cerebrospinal fluid; doctors then check whether walking and thinking temporarily improve. Improvement suggests the person is likely to benefit from a shunt.

Which symptom improves most after a shunt?

Walking (gait) is usually the most responsive; cognition and bladder control improve less consistently, and results are best when treatment is done earlier.

Where is NPH treated in Singapore?

At the National Neuroscience Institute and partner hospitals, by neurology and neurosurgery teams. A GP or specialist referral is the usual route.

Normal Pressure Hydrocephalus (NPH): A Treatable Cause (Singapore)

Written & reviewed by the BestDoctors.sg editorial team · Last updated 1 Sep 2026 · General information, not medical advice

Quick answer. Normal pressure hydrocephalus (NPH) is a build-up of cerebrospinal fluid (CSF) in the brain’s ventricles that occurs despite the pressure staying normal or near-normal. It mainly affects older adults and produces a classic triad of walking difficulty, cognitive decline and urinary incontinence. It matters because it is one of the few potentially treatable and sometimes reversible causes of dementia-like symptoms and walking problems – so it should not be dismissed as “just ageing.” Diagnosis uses brain imaging plus tests such as a large-volume lumbar puncture (“tap test”), and treatment is usually a shunt to drain the excess fluid.

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NPH is important precisely because it is treatable – yet it is easily mistaken for Alzheimer’s or Parkinson’s and dismissed as normal ageing. Recognising the triad can lead to treatment that restores mobility and independence.

What it is

The brain and spinal cord are bathed in cerebrospinal fluid (CSF), a clear liquid that cushions the brain, carries away waste and is constantly made, circulated and reabsorbed. The fluid flows through connected spaces inside the brain called the ventricles. In NPH, the delicate balance between how much CSF is produced and how much is absorbed is disrupted, so fluid gradually accumulates and the ventricles enlarge. The distinctive feature is that the measured pressure inside the head remains normal or only intermittently raised – unlike the sudden, severe pressure seen in other forms of hydrocephalus. This is why the condition builds slowly and quietly, and why its symptoms are so often mistaken for ordinary ageing or another brain disorder.

NPH mainly affects older adults. It matters because, among the many causes of a decline in walking, thinking and continence in later life, it is one of the few that can potentially be treated and sometimes partly reversed. Recognising it therefore opens a door that most dementia-like illnesses do not.

The classic triad

Doctors describe a classic triad of symptoms. Not everyone has all three, and they can appear at different times – but together they are the fingerprint that should prompt an assessment.

Walking difficulty – usually the earliest and most prominent feature. The gait becomes slow, shuffling and wide-based, and is often described as “magnetic,” as though the feet are stuck to the floor. People struggle to start walking, to turn, and to lift their feet cleanly, and they feel unsteady – all of which raises the risk of falls.
Problems with thinking and memory – mental slowing, poor concentration, difficulty planning and forgetfulness that can closely resemble dementia. The changes are often gradual and easy to attribute to age alone.
Loss of bladder control – typically beginning as a sudden urge to pass urine and progressing to urinary incontinence. This part of the triad often appears later than the walking problem.

The walking problem is usually the most prominent symptom and the first to appear, which is one reason a careful gait assessment is so central to diagnosis.

Why it is often missed

NPH is frequently overlooked because each part of its triad overlaps with a common condition of ageing. The shuffling, unsteady walk can look like Parkinson’s disease; the memory and thinking changes can look like Alzheimer’s and other dementias; and the urinary urgency can be put down to an ordinary bladder or prostate problem. Because all three are so common in later life, the symptoms are easily attributed to “just getting old” or to one of these better-known diagnoses, and the treatable possibility of NPH is never explored. Dismissing the symptoms as inevitable ageing can cost someone a treatable diagnosis, which is precisely why it deserves specialist consideration when the triad appears together.

Causes

In many people no clear cause is ever found; this is called idiopathic NPH. In others, it is secondary – developing after an event that disturbs the normal flow or absorption of CSF. Recognised triggers include a previous head injury, bleeding in or around the brain, a past infection such as meningitis, and other brain conditions such as a tumour or previous brain surgery. Whatever the trigger, the end result is the same: CSF is not cleared as efficiently as it is produced, the ventricles enlarge, and the triad of symptoms slowly emerges.

How it is diagnosed

Diagnosis rests on a careful assessment by a specialist – usually a neurologist or neurosurgeon, often alongside a geriatrician – who pieces together the history, the pattern of symptoms and the results of tests. There is no single test that confirms NPH; instead, the diagnosis is built up in steps.

Brain imaging – a CT or MRI scan is used to look at the ventricles. In NPH they appear enlarged out of proportion to any general shrinkage of the brain, and imaging also helps rule out other explanations for the symptoms.
Clinical and gait assessment – the walking pattern, balance, thinking and continence are examined carefully, often with the gait recorded so that any change can be measured objectively.
CSF testing – importantly, tests that involve removing some spinal fluid help predict whether treatment will help. In a large-volume lumbar puncture (“tap test”), a quantity of CSF is drained and walking and thinking are reassessed shortly afterwards. A temporary improvement suggests that draining the fluid more permanently, with a shunt, is likely to help. In some cases the specialist may instead monitor over a longer period using continuous drainage. These predictive tests are central, because they help select the people most likely to benefit from surgery.

Treatment

The main treatment is surgery to insert a shunt – a thin, soft tube with a valve that drains excess CSF away from a ventricle in the brain to another part of the body, usually the abdomen (the tummy), where the fluid is harmlessly reabsorbed. This is commonly called a ventriculoperitoneal shunt. By continuously diverting the surplus fluid, the shunt relieves the pressure effects on the brain and can improve symptoms – especially walking – in suitable people.

Crucially, not everyone benefits, which is why careful selection through imaging and the tap test matters so much. The people most likely to improve are those whose gait responded to CSF removal and who are treated before the symptoms become long-standing. In Singapore, adult hydrocephalus is assessed and managed by neurology and neurosurgery teams, including at the National Neuroscience Institute (NNI) and partner hospitals, often with input from geriatric medicine and rehabilitation services.

What to expect and realistic outcomes

Outcomes vary from person to person, and it helps to have realistic expectations. Walking often improves the most and can improve relatively soon after a successful shunt, sometimes strikingly so. Thinking, memory and bladder symptoms tend to respond less predictably – some people notice clear gains, others only modest ones – and improvement is generally greater when treatment happens earlier, before symptoms are entrenched. A shunt is also a long-term implant that needs ongoing monitoring: the valve, tubing and drainage rate all need to keep working correctly, and follow-up is arranged so that any problem can be picked up and adjusted. It is normal to have regular reviews for many years after surgery.

Risks of treatment

As with any brain surgery, and with any implanted shunt, there are risks to weigh against the potential benefits. These include infection, bleeding, blockage of the shunt, and problems with the amount of fluid drained – either over-drainage or under-drainage – which can cause new symptoms and sometimes need the valve to be adjusted or the shunt revised. The specialist team weighs these risks carefully against the likelihood of benefit, which is another reason patient selection is so important. After surgery, warning signs such as fever, a worsening or new headache, drowsiness, vomiting, or any new neurological symptoms should be reported to the medical team urgently, as they may indicate infection, bleeding or a shunt problem.

Living with it and self-care

Alongside surgery, rehabilitation plays an important role. Physiotherapy helps rebuild strength, balance and confidence in walking, and occupational therapy can help with daily activities. Falls prevention is a priority both before and after treatment, given the unsteady gait: removing trip hazards at home, good lighting, suitable footwear, grab bars and walking aids where appropriate all reduce risk. Regular follow-up with the neurosurgical and rehabilitation teams allows the shunt to be monitored and the recovery supported over time. Family members and carers are an important part of this, helping to notice changes in walking, thinking or continence and to keep follow-up appointments. Trusted local resources such as HealthHub can help patients and families understand the condition and plan ahead.

When to see a doctor

See a doctor if an older adult develops a new shuffling or unsteady walk, unexplained falls, memory or thinking changes, or new urinary incontinence – particularly when these occur together – rather than assuming it is normal ageing. Because NPH may be treatable, and sometimes partly reversible, an early assessment is worthwhile even when the symptoms seem mild. After shunt surgery, seek help urgently if there is fever, a worsening or new headache, increasing drowsiness, vomiting or any new symptoms, as these can signal a complication that needs prompt attention.

Related brain & nerve conditions

Sources

National Neuroscience Institute (NNI), Singapore — adult hydrocephalus (definition; causes; imaging; shunt treatment; managed by NNI/SingHealth neuroscience teams).
Cleveland Clinic / Alzheimer’s Association — normal pressure hydrocephalus (the triad; a treatable/reversible dementia mimic; the tap test; shunt; gait most responsive). Prevalence figures vary by source and are approximate.
Peer-reviewed literature — large-volume lumbar puncture (tap test) methodology and gait reassessment.

General information only. This guide is general information about a brain or nerve condition and is not a diagnosis or personalised medical advice. See a doctor — a GP or a neurologist — for assessment, tests and treatment. Call 995 for stroke symptoms (face drooping, arm weakness, slurred speech), a sudden severe “worst-ever” headache, a first or prolonged seizure, or a rapidly worsening loss of movement, consciousness or breathing.

Normal Pressure Hydrocephalus (NPH) in Singapore