Wet, Wobbly & Wacky: Normal Pressure Hydrocephalus

The term “wet, wobbly and wacky” doesn’t seem like it belongs in a medical journal or article about health. Yet it does, and you’ve likely heard that term instead of the medical condition it refers to.

The condition is called normal-pressure hydrocephalus (NPH) and it refers to an excess of cerebrospinal fluid.

There’s good and bad news in regard to NPH. The bad news is that it is often misdiagnosed or underdiagnosed through a combination of similar symptoms to other conditions and a lack of awareness about the condition.

The good news is that it’s a treatable condition and a potentially reversible cause of dementia. So if it’s properly diagnosed, you can expect more significant average recovery than you can from many related conditions.

The full scope of the condition and its treatments should be discussed with your doctor. Below, though, we aim to provide some basics on NPH so that you can assess whether or not to test for it and also increase your awareness of it as you and your loved ones age.

What is Normal Pressure Hydrocephalus (NPH)?

Normal pressure hydrocephalus is a chronic condition that involves an abnormal accumulation of cerebrospinal fluid (CSF) in the brain’s ventricles.

Why NPH Occurs

The condition primarily affects older adults. Leading theories suggest it has to do with the body’s reduced ability to absorb and drain fluid from the brain’s ventricles.

That said, the condition isn’t perfectly understood. It’s been known for over half a century, but the details of its causes are not perfectly known.

Science Direct calls it “...the expression of a progressive discrepancy between the mostly constant production of 600 mL of CSF by the ventricular choroid plexus each 24 hours and the progressive reduction in the capacity of the intracranial CSF pathways to manage this volume.”

This, again, doesn’t get into root causes, but the discrepancy that leads to the central issues of NPH is well documented, and it involves some obstruction of CSF drainage.

Why is It Called Wet, Wobbly and Wacky?

The somewhat odd mnemonic of wet wobbly wacky is the result of the primary symptoms of NPH.

Urinary incontinence, gait instability and cognitive changes, respectively, correspond to wet, wobbly and wacky.

You can argue whether or not such a silly-sounding phrase is the most appropriate for such a serious condition, but this is nevertheless how many people understand and refer to it.

Symptoms of Normal Pressure Hydrocephalus

The “wet wobbly wacky” phrase above speaks to each of the major issues commonly associated with NPH, a triad of symptoms that typically accompany the condition.

Urinary incontinence - or lack of bladder control - is one of the symptom triad. Some medical sources differentiate between NPH-induced urinary incontinence and urinary urgency or frequent urination. These can seem similar, but often have different root causes.

Particularly since urinary incontinence is often a later-stage symptom of NPH, it’s not always the first or most prevalent symptom, especially since urinary problems can occur for other reasons as well.

Gait instability is generally the most frequent symptom, and one of the earliest. This can result in shuffling, stumbling, trouble with gait initiation and an inability to climb stairs, among other issues caused by the symptom.

Similar to urinary incontinence, though, gait instability isn’t only caused by NPH. Other conditions such as Parkinson’s disease and Alzheimer’s disease can manifest similarly in people.

Those conditions are more well-known and have been studied more. This can make it harder to distinguish NPH from other possible conditions, and is what sometimes leads to misdiagnosis.

Lastly, cognitive changes can be pronounced in those with NPH. Cognitive impairment is another way of framing these changes. “Cognitive changes” is a broad term, so there isn’t one specific change to look out for. Changes can include a drop in one’s ability to concentrate, depressive symptoms, memory loss, and slower thinking and reaction times.

PsychDB, a psychiatry reference for students, indicates that only in about 25% of cases do all three symptoms occur in those suffering from NPH. So while you would expect at least one and possibly two of these symptoms, not all three need to be present for it to be NPH.

Possible Treatments for Normal-Pressure Hydrocephalus

The American Academy of Neurology states that shunting is a possible solution for NPH. Shunt surgery is required for this.

The chances of subjective improvement, according to their findings, are close to 100%.

Gait disturbance is the only one of the three primary symptoms that they assign an objective measurement to, but even here there was marked improvement in the majority of those in the study. Other methods of draining cerebrospinal fluid are mentioned in medical assessments elsewhere that have similarly shown results.

This is great news for people with NPH, so long as it’s properly diagnosed and treated.

Dementia or NPH?

You’ve probably noted that NPH has many of the same signs and symptoms of dementia. Whether a specific form of dementia such as Alzheimer’s or related conditions, the effects can be difficult to distinguish from NPH.

The National Library of Medicine actually calls it a cause of dementia. They note that it’s reversible, though, so diagnosis and early treatment are especially important. This is in juxtaposition with their admission that NPH remains underdiagnosed and undertreated.

Whether a condition is NPH or another form of cognitive decline is something that requires testing and consultation with a medical professional. If you perceive the symptoms of NPH in yourself or a loved one, it’s worth having a discussion with trusted medical professionals and making sure you have a clear diagnosis that you can act quickly upon.

Wet Wobbly Wacky and You: Hope For Treatment

The short version is that awareness of NPH is half the battle. Proper diagnosis and treatment are the next steps, and positive outcomes are entirely possible with early detection. A lifetime of undiagnosed hydrocephalus can be a nightmare for individuals and their families, but treatment is possible once diagnosed.

The longer version of your story with NPH involves your specific symptoms and treatment, and may require several medical consultations and treatments to diagnose and/or treat properly.

Awareness is key, though, and the good news is that NPH remains one of the most reversible cognitive conditions that affects people as they age. There are never guarantees with medical treatments, but if you stay vigilant and informed, you’ll have a better chance of mitigating or eliminating symptoms, increasing and maintaining your quality of life for years to come.