What are the key clinical features to consider when diagnosing hydrocephalus in adults?

When diagnosing hydrocephalus in adults, the key clinical features to consider include the classic triad of gait disturbance, cognitive impairment, and urinary incontinence. Gait disturbance is often the earliest and most prominent symptom, typically presenting as a broad-based, magnetic, or shuffling gait with difficulty initiating steps. Cognitive impairment usually manifests as a subcortical dementia characterized by slowed thinking, impaired attention, and executive dysfunction rather than memory loss alone. Urinary symptoms often begin as urgency and frequency progressing to incontinence in later stages. These features are characteristic of idiopathic normal pressure hydrocephalus (iNPH), the most common form in adults, and should prompt further investigation with neuroimaging to confirm ventricular enlargement disproportionate to cortical atrophy. Additional signs may include subtle motor deficits and postural instability. It is important to differentiate these symptoms from other neurodegenerative disorders, as hydrocephalus is potentially reversible with appropriate intervention such as shunting NICE NG228 Carswell 2023Tipton et al. 2024.