NPH 10-30-12 Morrone-Strupinsky presentation

Managing cognitive and
emotional changes associated
with NPH
Jeannine Morrone-Strupinsky, Ph.D., ABPP-CN
October 30, 2012
Plan of talk
 Review cognitive changes associated with NPH
 Offer suggestions for managing cognitive
 Review mood/behavioral changes associated
with NPH
 Offer suggestions for managing
mood/behavioral changes
Q & A
NPH—A Brief Review
 First described in 1965.
 Abnormal buildup of CSF in the ventricles with
high normal CSF pressure.
 Enlargement of the ventricles causes stretching
of surrounding brain tissue (neurons) and blood
vessels, particularly in the frontal lobes.
How NPH looks in the brain
Normal MRI
T2-weighted MRI showing
dilatation of ventricles out of
proportion to sulcal atrophy in a
patient with normal pressure
CT head scan of a patient with normal
pressure hydrocephalus showing dilated
ventricles. The arrow points to a
rounded frontal horn.
NPH—A Brief Review
 Can occur in people of any age, but is most
common in older adults (60s and 70s).
 Secondary NPH is the result of brain injury/insult
(e.g., trauma, infection, tumor).
 “Idiopathic” NPH is due to unknown causes.
 NPH may account for up to 5% of individuals
with dementia.
Clinical triad
 Incontinence
 Inability to hold urine
 Frequent urination
 Urgency to urinate
 Gait disturbance
Wide-based gait
Leg weakness
Sudden falls
Shuffling steps
Difficulty taking first step because feet are “stuck” to the floor
“freezing” while walking
 Cognitive impairment (next slide)
Cognitive Effects of NPH
Slowing down of thoughts
Memory impairment—decline in active
retrieval (immediate and delayed recall) with
preserved memory storage (recognition)
Visuospatial perception and visuoconstruction
may be impaired
Absence of aphasia, apraxia, and agnosia
(“cortical features” seen in AD)
Impairment in executive functions
Cognitive Effects of NPH
 Executive functions (“CEO” of the brain)
Planning (and prioritizing)
Thinking in a flexible manner (adjusting to
changing situations, coming up with new
Concentration/working memory (i.e., dialing
new phone numbers)
Abstract thinking (learning from experience by
extracting broader meaning of events)
Managing time
Initiating appropriate actions and inhibiting
inappropriate actions (impulsivity)
Selecting relevant sensory information
(focusing attention on what is relevant; i.e.,
being able to filter out background noise)
Cognitive Effects of NPH
 Regarding memory, individuals with NPH
display impaired free recall of information but
tend to benefit from cues and show relatively
spared recognition. This has led some to
propose that the mechanism of memory
failures may be retrieval search while the
storage capacity is preserved.
 Memory retrieval is performed by the frontal
lobes (affected by bulging ventricles).
Effects of shunting on cognitive
 NPH is described as a reversible form of
 However, statistics vary considerably regarding
cognitive improvement (30-40% in INPH and 5070% in secondary NPH).
 Memory tends to improve more than executive
 More improvement is seen in younger
individuals and in women, and in those without
other causes of impairment.
 Gait impairment and urinary incontinence
are more likely to improve.
5 reasons why a neuropsychological
examination is requested by a physician
 To find possible problems with brain
 To help clarify a patient’s diagnosis.
 To define an individual’s relative brain-related
strengths and weaknesses.
 To guide treatment, or to help patients make
educational or vocational decisions.
 To determine whether or not there are any
changes in a patient’s cognitive and
emotional functions over time.
National Academy of Neuropsychology
Role of the neuropsychologist
 A neuropsychological examination is a
systematic and scientifically-based
assessment of a person’s thinking, problemsolving, and memory capacity that may reveal
something about the state of brain function.
 The pattern of test findings allows the
examining clinician to develop an informed
opinion about the patient’s higher cerebral
 Ultimately, the physician must integrate
results from a variety of tests to determine the
Compensating for cognitive
difficulties in NPH
 If the person with NPH has difficulty shifting
tasks quickly
 give adequate notice that he or she needs to get
ready to go somewhere
 post an agenda for the day
 If the person with NPH has difficulty focusing
 reduce background distractions
 perform only one activity at a time, and try to
complete the activity before starting another
 take frequent breaks to allow the individual to
Compensations for cognitive
difficulties in NPH
 If the person with NPH has difficulty sequencing
 use procedural checklists (i.e. to program TiVo, cook
meals, follow a grooming routine)
 If the person with NPH has difficulty making
 limit choices/provide options
 use concrete examples
 break down large projects into component parts
Compensating for cognitive difficulties in
 If the person with NPH has
difficulty recalling information
 use a memory notebook, day
planner, or voice recorder
 use placards
 use a beeping watch/timer to
remember to do something
(i.e., turn off hose in the yard)
 use a pill box
 use forms to remember to do
things that occur periodically
(i.e., change air filters)
 provide cues to aid memory
 use organizing strategies
 face-name recall technique
Face-name recall technique
 Focus on the name. Repeat it to yourself several times.
 Associate the name with something already stored in
your memory.
 If you know someone with the same name, that will be the
association. Visualize an image of the new person with
the person you already know who has the same name.
 If the person has a name that you do not know, create an
association by breaking down the name into words to
which you form visual images.
 Visualize the person with the visual images you have
created. Drawing a picture with the association or
making up a short story about the images helps even
Famous Margarets…
Maggie Bobrowitz, RN, MBA
Neuroscience Program
Grouping example
 Read the following list of sports one time. When
you are done, write down as many of the sports
as you can without looking back at the list.
snow skiing
long jump
100-m dash
ice skating
high jump
Grouping example
 You can organize material by grouping similar
concepts, or related ideas together.
 For example
 Winter sports
 Track and field sports
 Sports using a ball
 Individual sports
 Team sports
Another grouping example…
NPH and mood changes
 Depression is present in some individuals with NPH.
Average prevalence of major depressive disorder in
the elderly population is 1.8%.
 DSM-IV criteria for depression (>5 of the following):
 depressed mood
 decreased interest (apathy*) or pleasure in activities
 significant weight loss*
 insomnia* or excessive sleep*
 psychomotor retardation or agitation
 loss of energy (anergia)*
 feelings of inappropriate guilt
 recurrent thoughts of death
Differentiating depression from apathy
 Sometimes it looks like the individual with NPH
is depressed, but rather s/he is apathetic or is
unconcerned or unaware of his or her condition.
 Apathy is defined as a primary loss of
motivation, loss of interest, and loss of effortful
behavior, features also present in depressed
 This is likely due to disruption of medial frontal
lobe functioning due to bulging of the ventricles
into the brain tissue.
Treatment of depression in NPH
 Treatment of depression in NPH is important because
depression has a negative influence on cognitive
performance, activities of daily living, and perceived
quality of life.
 In the case of mild depression, options include
behavioral activation and/or supportive psychotherapy.
 A clinical psychologist or social worker can be helpful in
this adjustment period, particularly in helping identify life
stressors that may be contributing to the depression.
 Psychotherapy also helps the individual with NPH accept
the diagnosis, employ coping strategies, and work
through the emotional consequences of having to deal
with the diagnosis.
Treatment of depression in NPH, cont’d
 A long-term plan must then be structured to
minimize stress and improve quality of life.
Patients should be encouraged to develop a
daily exercise routine within their capabilities.
 In case of more significant depression,
pharmacological treatment is warranted
(antidepressant medication).
 Keenan et al. (2005) demonstrated a reduction
in reported symptoms of apathy following a dose
of methylphenidate, which increases the action
of dopamine, a chemical in the brain.
NPH and sleep disturbance
 Individuals with NPH may experience sleep
disturbance. This can be due to changes in
mood or in the functioning of brain regions
associated with sleep.
 Practicing sleep hygiene can improve sleep.
 Go to bed the same time every night.
 Keep bedroom cool, dark, and quiet.
 Use the bedroom only for sleep and intimacy.
 Get up and do something sedentary if you are
unable to fall asleep.
“Pseudodementia” in NPH
 A common referral question is the differentiation
of cognitive dysfunction caused by NPH from a
“pseudodementia” attributable to depression.
 Patients with NPH and depression show worse
cognitive performance when compared with
patients without depression, particularly on tests
of executive functioning.
 Depression and even mild cognitive impairment
contribute significantly to disability in
patients with NPH.
Salvador Dalí. (Spanish, 1904-1989). The
Persistence of Memory. 1931.

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