Objective:

To assess neurologists’ opinions and practices regarding the evaluation of possible/probable iNPH in the state of Virginia to help streamline the care of these patients.

Background:

Idiopathic normal pressure hydrocephalus (iNPH) is a form of communicating hydrocephalus characterized by gait and/or balance problems, cognitive impairment, and urinary incontinence (Hakim’s triad). The differential diagnosis for iNPH includes conditions across neurological subspecialties including cognitive/behavioral neurology, movement disorders, neuromuscular, and neurosurgery. Thus, the evaluation of these patients is not streamlined.

Design/Methods:

In an IRB-approved study, 184 attending neurologists and neurology advanced practice providers practicing in the state of Virginia were emailed an anonymous 13-item survey including demographic information, iNPH evaluation practices, and opinion on which provider evaluation is most appropriate to diagnose iNPH (cognitive/behavioral, general neurology, movement disorders, neurosurgery alone, or other).

Results:

Thirty-nine participants completed the survey (21% response rate). Eighty-one percent were attending physicians with 87% practicing at an academic center and 25% reporting subspecialty training. Sixty-one percent evaluated 0-9 patients, 26% 10-19 patients, 10% 20-29 patients, and 3% over 30 patients per year for a diagnosis of iNPH. Eighty-four percent were likely/very likely to recommend a high-volume lumbar puncture as part of their evaluation. Fifty-five percent were likely/very likely to refer to a subspecialist, most frequently neuropsychology (43%) and movement disorders (39%). Forty-six percent believed movement disorders is the most appropriate subspecialty to diagnose iNPH followed by general (18%), other (18%), cognitive/behavioral (14%), and neurosurgery alone (4%). Eighty-six percent stated they would refer patients to a streamlined iNPH multidisciplinary diagnostic clinic if available.

Conclusions:

The symptoms of Hakim’s triad span multiple subspecialities, but Virginia providers desire a streamlined approach with a multidisciplinary clinic that includes a movement disorders evaluation. This is appropriate considering gait is the most shunt-responsive iNPH symptom, and movement disorders commonly evaluates neurodegenerative gait disorders that can mimic iNPH.