Normal pressure hydrocephalus (NPH) is clinical syndrome of dementia, gait disturbance, and urinary incontinence that progresses over a period of weeks to years. Urinary incontinence, a late symptom, occurs in less than 50% of patients. If untreated, NPH progresses resulting in an inability to stand, akinetic rigidity, and withdrawn behavior. The differential diagnosis includes Parkinson's disease, bifrontal brain disease due to tumor, metastases, cerebral infarction, aqueductal stenosis, metabolic encephalopathy, and Alzheimer's disease. When NPH is suspected clinically, computerized tomography (with contrast enhancement) reveals ventriculomegaly, minimal or absence of cortical atrophy, periventricular lucencies, and nearly normal-sized subarachnoid space. Magnetic resonance imaging (MRI) is the study of choice to evaluate ventriculomegaly and functional imaging of cerebrospinal fluid (CSF) flow. The role of the emergency physician is to consider the diagnosis of NPH in patients with dementia and gait disturbance and to initiate appropriate referral.

The gait abnormalities are indicative of some disorder of the nervous system. This chapter describes different types of gait disturbance with regard to localization and specific neurological disorders. The different gait disturbances are: senescent gait or early gait apraxia, advanced senescent gait (late gait apraxia), hemiparetic gait, spastic gait, ataxic gait, staggering gait, steppage gait, waddling gait, hysterical gait and antalgic gait. Antalgic gait results from a shortened stance phase or a painful limb. Osteoarthritis is a common cause. The gait of patients with Parkinson's disease and related disorders is stereotyped but may be confused with senescent gait. There is usually a flexion of all limbs and trunk and a tendency to lean forward and accelerate with walking, a disturbance referred to as festination. Tremor commonly accompanies the gait disturbance. Universal flexion is typically associated with the gait of Parkinson's disease.