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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 regarding 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 you get a proper diagnosis of NPH, you can expect a 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 involving an abnormal accumulation of cerebrospinal fluid (CSF) in the brain’s ventricles.
Cerebrospinal fluid is a clear and watery fluid that provides nutrients and protection to the spinal cord and brain. Ventricles are the fluid-filled spaces in your brain that hold CSF.
As the name would imply, NPH happens in the normal CSF pressure range. However, this elevated cerebrospinal fluid level, even if only slightly above average, can still cause serious symptoms and problems.
Why NPH Occurs
Normal pressure hydrocephalus 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. Scientists and doctors have known about NPH for over half a century, but the details of what causes the condition are unknown.
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.”
Again, this doesn’t get into the root causes of hydrocephalus, 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 and wacky (sometimes known as wet, wobbly, and wonky) is the result of the primary NPH symptoms.
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 and 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 the “wet” 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, represented by the term “wobbly,” is generally the most frequent symptom and one of the earliest. This can result in issues like:
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Shuffling and stumbling
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Trouble with gait initiation
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An inability to climb stairs or difficulty lifting your feet
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Rotating your toes outwards when walking
Similar to urinary incontinence, though, gait instability isn’t only caused by NPH. Neurodegenerative diseases or conditions such as Parkinson’s disease and Alzheimer’s disease can manifest similarly in some 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, known as “wacky” or “wonky,” 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.
Dementia or NPH: Diagnosing Normal Pressure Hydrocephalus
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 NPH 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.
Dementia and NPH also arise around the same age, and around 30% of those with normal pressure hydrocephalus also have Alzheimer’s disease or a similar condition that impacts cognitive abilities.
Whether a condition is NPH or another form of cognitive decline is something that requires testing and consultation with a medical professional.
Doctors use diagnostic imaging tests like magnetic resonance imaging (MRI) scans to observe fluid build up in the brain. Your doctor may also use a CT scan to help rule out other conditions; however, this scan cannot diagnose NPH.
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 NPH diagnosis that you can act quickly upon.
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.
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.
If you or your loved one need help with long-term care due to normal pressure hydrocephalus or a related condition, LTC News's care search tool can help. There are tens of thousands of listings in our directory that can help you find and compare high-quality care options close to home.
LTC News also offers several educational resources on long-term care, caregiving, and information on specific conditions. Here are a few articles you may be interested in:
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How To Prevent or Delay Dementia and Alzheimer's Disease – NPH and dementia are related and often confusing conditions. This article can help you learn how to slow the disease's progression and mitigate early symptoms.
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Nutrition Tips for Older Adults: Wellness, Aging, and Diet – This article offers insights into maintaining health as you age, including nutrition, lifestyle, and daily movement recommendations.