The timed up and go test in idiopathic normal pressure hydrocephalus: a Nationwide Study of 1300 patients

Abstract Background The aim of this study was to describe the outcome measure timed up and go (TUG) in a large, nationwide cohort of patients with idiopathic normal pressure hydrocephalus (iNPH) pre- and post-operatively. Furthermore, to compare the TUG test to the 10-m walk test (10MWT), the iNPH scale, the modified Rankin scale (mRS) and the Mini Mental State Examination (MMSE), which are commonly applied in clinical assessment of iNPH. Methods Patients with iNPH (n = 1300), registered in the Swedish Hydrocephalus Quality Registry (SHQR), were included. All data were retrieved from the SHQR except the 10MWT, which was collected from patient medical records. Clinical scales were examined pre- and 3 months post-operatively. Data were dichotomised by sex, age, and preoperative TUG time. Results Preoperative TUG values were 19.0 [14.0–26.0] s (median [IQR]) and 23 [18–30] steps. Post-operatively, significant improvements to 14.0 [11.0–20.0] s and 19 [15–25] steps were seen. TUG time and steps were higher in women compared to men (p < 0.001) but there was no sex difference in improvement rate. Worse preoperative TUG and younger age favoured improvement. TUG was highly correlated to the 10MWT, but correlations of post-operative changes were only low to moderate between all scales (r = 0.22–0.61). Conclusions This study establishes the distribution of TUG in iNPH patients and shows that the test captures important clinical features that improve after surgery independent of sex and in all age groups, confirming the clinical value of the TUG test. TUG performance is associated with performance on the 10MWT pre- and post-operatively. However, the weak correlations in post-operative change to the 10MWT and other established outcome measures indicate an additional value of TUG when assessing the effects of shunt surgery.

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Waiting time for surgery influences the outcome in idiopathic normal pressure hydrocephalus — a population-based study

Acta Neurochirurgica ◽

10.1007/s00701-021-05085-7 ◽

2021 ◽

Author(s):

Christine Chidiac ◽

N. Sundström ◽

M. Tullberg ◽

L. Arvidsson ◽

M. Olivecrona

Keyword(s):

Clinical Outcome ◽

Waiting Time ◽

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Population Based ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Shunt Surgery ◽

Timed Up And Go ◽

Population Based Study ◽

Quality Registry

Abstract Introduction Idiopathic normal pressure hydrocephalus (iNPH) is a disease that comes with a great impact on the patient’s life. The only treatment for iNPH, which is a progressive disease, is shunt surgery. It is previously indicated that early intervention might be of importance for the outcome. Aim To investigate if a longer waiting time for surgery, negatively influences the clinical outcome. Methods Eligible for this study were all iNPH patients (n = 3007) registered in the Swedish Hydrocephalus Quality Registry (SHQR) during 1st of January 2004–12th of June 2019. Waiting time, defined as time between the decision to accept a patient for surgery and shunt surgery, was divided into the intervals ≤ 3, 3.1–5.9 and ≥ 6 months. Clinical outcome was assessed 3 and 12 months after surgery using the modified iNPH scale, the Timed Up and Go (TUG) test and the mini mental state examination (MMSE). Results Three months after surgery, 57% of the patients with ≤ 3 months waiting time showed an improvement in modified iNPH scale (≥ 5 points) whereas 52% and 46% of patients with 3.1–5.9 and ≥ 6 months waiting time respectively improved (p = 0.0115). At 12 months of follow-up, the corresponding numbers were 61%, 52% and 51% respectively (p = 0.0536). Conclusions This population-based study showed that in patients with iNPH, shunt surgery should be performed within 3 months of decision to surgery, to attain the best outcome.

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Long-term effects of complications and vascular comorbidity in idiopathic normal pressure hydrocephalus: a quality registry study

Journal of Neurology ◽

10.1007/s00415-017-8680-z ◽

2017 ◽

Vol 265 (1) ◽

pp. 178-186 ◽

Cited By ~ 13

Author(s):

Kerstin Andrén ◽

Carsten Wikkelsö ◽

Nina Sundström ◽

Simon Agerskov ◽

Hanna Israelsson ◽

...

Keyword(s):

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Registry Study ◽

Long Term Effects ◽

Quality Registry ◽

Vascular Comorbidity

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Timed up and go test at tap test and shunt surgery in idiopathic normal pressure hydrocephalus

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000334 ◽

2017 ◽

Vol 7 (2) ◽

pp. 98-108 ◽

Cited By ~ 12

Author(s):

Shigeki Yamada ◽

Masatsune Ishikawa ◽

Masakazu Miyajima ◽

Madoka Nakajima ◽

Masamichi Atsuchi ◽

...

Keyword(s):

Normal Pressure Hydrocephalus ◽

Ventriculoperitoneal Shunt ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Shunt Surgery ◽

Timed Up And Go ◽

Tap Test ◽

Lumboperitoneal Shunt ◽

Shunt Implantation ◽

Percent Improvement

AbstractBackground:The 3-meter Timed Up and Go test (TUG) is a reliable quantitative test for assessment of gait and balance. We aimed to establish an optimal threshold of TUG at the tap test for predicting outcomes 12 months after shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).Methods:The TUG was measured in a total of 151 patients with possible iNPH before and after a tap test and 12 months after shunt surgery. Among them, 81 patients underwent ventriculoperitoneal shunt implantation (SINPHONI) and 70 underwent lumboperitoneal shunt implantation (SINPHONI-2). The areas under the curve (AUCs), sensitivities, and specificities for predicting shunt effectiveness were assessed.Results:The simple differences of time on TUG at the tap test were significantly more accurate for predicting shunt effectiveness than percent improvement of time. The highest AUC for the synchronized moving cutoff point of TUG time was 0.81 (sensitivity 81.0%; specificity 81.6%) at the threshold of 5 seconds in the SINPHONI-2. For predicting improvements of ≥10 seconds 12 months after lumboperitoneal shunt implantation, the AUC was 0.90, and the sensitivity and specificity at the threshold of 5.6 seconds were 83.3% and 81.0%. Only for patients with a <5-second improvement at the tap test, ventriculoperitoneal shunt implantation conveyed significantly better improvements in TUG time 12 months after surgery than lumboperitoneal shunt implantation.Conclusions:An improvement of 5 seconds was a useful threshold of TUG time at the tap test for predicting a ≥10-second improvement 12 months after shunt surgery, rather than the percent improvement of TUG time.

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Alzheimer’s Disease Biomarkers in Idiopathic Normal Pressure Hydrocephalus: Linking Functional Connectivity and Clinical Outcome

Journal of Alzheimer s Disease ◽

10.3233/jad-210534 ◽

2021 ◽

Vol 83 (4) ◽

pp. 1717-1728 ◽

Cited By ~ 1

Author(s):

Giulia Bommarito ◽

Dimitri Van De Ville ◽

Giovanni B. Frisoni ◽

Valentina Garibotto ◽

Federica Ribaldi ◽

...

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Cerebrospinal Fluid ◽

Functional Connectivity ◽

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Cognitive Status ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Response To Treatment ◽

Timed Up And Go

Background: Alzheimer’s disease (AD) pathology impacts the response to treatment in patients with idiopathic normal pressure hydrocephalus (iNPH), possibly through changes in resting-state functional connectivity (rs-FC). Objective: To explore the relationship between cerebrospinal fluid biomarkers of AD and the default mode network (DMN)/hippocampal rs-FC in iNPH patients, based on their outcome after cerebrospinal fluid tap test (CSFTT), and in patients with AD. Methods: Twenty-six iNPH patients (mean age: 79.9±5.9 years; 12 females) underwent MRI and clinical assessment before and after CSFTT and were classified as responders (Resp) or not (NResp), based on the improvement at the timed up and go test and walking speed. Eleven AD patients (mean age: 70.91±5.2 years; 5 females), matched to iNPH for cognitive status, were also included. DMN and hippocampal rs-FC was related to amyloid-β42 and phosphorylated tau (pTau) levels. Results: Lower amyloid-β42 levels were associated with reduced inter- and intra-network rs-FC in NResp, and the interaction between amyloid-β42 and rs-FC was a predictor of outcome after CSFTT. The rs-FC between DMN and salience networks positively correlated to amyloid-β42 levels in both NResp and AD patients. The increase in the inter-network rs-FC after CSFTT was associated with higher pTau and lower amyloid-β42 levels in NResp, and to lower pTau levels in Resp. Conclusion: Amyloid-β42 and pTau impact on rs-FC and its changes after CSFTT in iNPH patients. The interaction between AD biomarkers and rs-FC might explain the responder status in iNPH.

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A randomized controlled dual-center trial on shunt complications in idiopathic normal-pressure hydrocephalus treated with gradually reduced or “fixed” pressure valve settings

Journal of Neurosurgery ◽

10.3171/2014.7.jns14283 ◽

2014 ◽

Vol 121 (5) ◽

pp. 1257-1263 ◽

Cited By ~ 28

Author(s):

Terje Sæhle ◽

Dan Farahmand ◽

Per Kristian Eide ◽

Magnus Tisell ◽

Carsten Wikkelsö

Keyword(s):

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Improvement Rate ◽

Vp Shunt ◽

Shunt Complications ◽

Pressure Setting ◽

Randomized Controlled ◽

Adjustable Valve ◽

Significant Difference

Object This study was undertaken to investigate whether a gradual reduction of the valve setting (opening pressure) decreases the complication rate in patients with idiopathic normal-pressure hydrocephalus (iNPH) treated with a ventriculoperitoneal (VP) shunt. Methods In this prospective double-blinded, randomized, controlled, dual-center study, a VP shunt with an adjustable valve was implanted in 68 patients with iNPH, randomized into two groups. In one group (the 20–4 group) the valve setting was initially set to 20 cm H2O and gradually reduced to 4 cm H2O over the course of the 6-month study period. In the other group (the 12 group), the valve was kept at a medium pressure setting of 12 cm H2O during the whole study period. The time to and type of complications (hematoma, infection, and mechanical problems) as well as overdrainage symptoms were recorded. Symptoms, signs, and outcome were assessed by means of the iNPH scale and the NPH grading scale. Results Six patients in the 20–4 group (22%) and 7 patients in the 12 group (23%) experienced a shunt complication; 9 had subdural hematomas, 3 mechanical obstructions, and 1 infection (no significant difference between groups). The frequency of overdrainage symptoms was significantly higher for a valve setting ≤ 12 cm H2O compared with a setting > 12 cm H2O. The 20–4 group had a higher improvement rate (88%) than the 12 group (62%) (p = 0.032). There was no significant relationship between complications and body mass index, the use of an antisiphon device, or the use of anticoagulants. Conclusions Gradual lowering of the valve setting to a mean of 7 cm H2O led to the same rate of shunt complications and overdrainage symptoms as a fixed valve setting at a mean of 13 cm H2O but was associated with a significantly better outcome.

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One-year outcome in patients with idiopathic normal-pressure hydrocephalus: comparison of lumboperitoneal shunt to ventriculoperitoneal shunt

Journal of Neurosurgery ◽

10.3171/2015.10.jns151894 ◽

2016 ◽

Vol 125 (6) ◽

pp. 1483-1492 ◽

Cited By ~ 33

Author(s):

Masakazu Miyajima ◽

Hiroaki Kazui ◽

Etsuro Mori ◽

Masatsune Ishikawa

Keyword(s):

Normal Pressure Hydrocephalus ◽

Ventriculoperitoneal Shunt ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Secondary Outcome ◽

Efficacy And Safety ◽

Serious Adverse Events ◽

Improvement Rate ◽

Minimal Invasiveness ◽

Programmable Valves

OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) is treated with cerebrospinal fluid shunting, and implantation of a ventriculoperitoneal shunt (VPS) is the current standard treatment. The objective of this study was to compare the efficacy and safety of VPSs and lumboperitoneal shunts (LPSs) for patients with iNPH. METHODS The authors conducted a prospective multicenter study of LPS use for patients with iNPH. Eighty-three patients with iNPH (age 60 to 85 years) who presented with ventriculomegaly and high-convexity and medial subarachnoid space tightness on MR images were recruited from 20 neurological or neurosurgical centers in Japan between March 1, 2010, and October 19, 2011. The primary outcome was the modified Rankin Scale (mRS) score 1 year after surgery, and the secondary outcome included scores on the iNPH grading scale (iNPHGS). A previously conducted VPS cohort study with the same inclusion criteria and primary and secondary end points was used as a historical control. RESULTS The proportion of patients who achieved a favorable outcome (i.e., improvement of at least 1 point in their mRS score) was 63% (95% CI 51%–73%) and was comparable to values reported with VPS implantation (69%, 95% CI 59%–78%). Using the iNPHGS, the 1-year improvement rate was 75% (95% CI 64%–84%) and was comparable to the rate found in the VPS study (77%, 95% CI 68%–84%). The proportion of patients experiencing serious adverse events (SAEs) and non-SAEs did not differ significantly between the groups at 1 year after surgery (SAEs: 19 [22%] of 87 LPS patients vs 15 [15%] of 100 VPS patients, p = 0.226; non-SAEs: 24 [27.6%] LPS patients vs 20 [20%] VPS patients, p = 0.223). However, shunt revisions were more common in LPS-treated patients than in VPS-treated patients (6 [7%] vs 1 [1%]). CONCLUSIONS The efficacy and safety rates for LPSs with programmable valves are comparable to those for VPSs for the treatment of patients with iNPH. Despite the relatively high shunt failure rate, an LPS can be the treatment of choice because of its minimal invasiveness and avoidance of brain injury.

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Clinical predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Acta Neurochirurgica ◽

10.1007/s00701-021-04922-z ◽

2021 ◽

Author(s):

Santhosh G. Thavarajasingam ◽

Mahmoud El-Khatib ◽

Mark Rea ◽

Salvatore Russo ◽

Johannes Lemcke ◽

...

Keyword(s):

Systematic Review ◽

Diagnostic Test ◽

Normal Pressure Hydrocephalus ◽

Meta Analysis ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Future Research ◽

Clinical Predictors ◽

Timed Up And Go ◽

Shunt Response

Abstract Background Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose. Objective To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests. Methods Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses. Results Thirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711. Conclusion Intraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude $$\ge$$ ≥ 4 mmHg, or 1- to 4-day ELD with an MMSE cut-off improvement $$\ge$$ ≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.

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Risk factors for developing subdural hematoma: a registry-based study in 1457 patients with shunted idiopathic normal pressure hydrocephalus

Journal of Neurosurgery ◽

10.3171/2019.10.jns191223 ◽

2020 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

Johan Gasslander ◽

Nina Sundström ◽

Anders Eklund ◽

Lars-Owe D. Koskinen ◽

Jan Malm

Keyword(s):

Risk Factors ◽

Normal Pressure Hydrocephalus ◽

Platelet Aggregation Inhibitors ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Routine Practice ◽

Opening Pressure ◽

Quality Registry ◽

Antiplatelet Medication ◽

Lower Opening

OBJECTIVESubdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH.METHODSThe Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004–2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs.RESULTSThe study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421–3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236–2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups.CONCLUSIONSiNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.

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Role of Endoscopic Third Ventriculostomy and Ventriculoperitoneal Shunt in Idiopathic Normal Pressure Hydrocephalus

Neurosurgery ◽

10.1227/neu.0b013e318285b37c ◽

2013 ◽

Vol 72 (5) ◽

pp. 845-854 ◽

Cited By ~ 37

Author(s):

Fernando Campos Gomes Pinto ◽

Felippe Saad ◽

Matheus Fernandes de Oliveira ◽

Renan Muralho Pereira ◽

Fernanda Letkaske de Miranda ◽

...

Keyword(s):

Normal Pressure Hydrocephalus ◽

Ventriculoperitoneal Shunt ◽

Endoscopic Third Ventriculostomy ◽

Normal Pressure ◽

Functional Independence ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Third Ventriculostomy ◽

Timed Up And Go ◽

Programmable Valve ◽

Significant Difference

Abstract BACKGROUND: Currently, the most common treatment for idiopathic normal pressure hydrocephalus (INPH) is a ventriculoperitoneal shunt (VPS), generally with programmable valve implantation. Endoscopic third ventriculostomy (ETV) is another treatment option, and it does not require prosthesis implantation. OBJECTIVE: To compare the functional neurological outcome in patients after 12 months of treatment with INPH by using 2 different techniques: ETV or VPS. METHODS: Randomized, parallel, open-label trial involving the study of 42 patients with INPH and a positive response to the tap test, from January 2009 to January 2012. ETV was performed with a rigid endoscope with a 30° lens (Minop, Aesculap), and VPS was performed with a fixed-pressure valve (PS Medical, Medtronic). The outcome was assessed 12 months after surgery. The neurological function outcomes were based on the results of 6 clinical scales: mini-mental, Berg balance, dynamic gait index, functional independence measure, timed up and go, and normal pressure hydrocephalus. RESULTS: There was a statistically significant difference between the 2 groups after 12 months of follow-ups, and the VPS group showed better improvement results (ETV = 50%, VPS = 76.9%). CONCLUSION: Compared with ETV, VPS is a superior method because it had better functional neurological outcomes 12 months after surgery.

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Risk of idiopathic normal pressure hydrocephalus in older inpatients with schizophrenia

International Psychogeriatrics ◽

10.1017/s1041610215001763 ◽

2015 ◽

Vol 28 (5) ◽

pp. 863-868 ◽

Cited By ~ 2

Author(s):

Yuta Yoshino ◽

Taku Yoshida ◽

Takaaki Mori ◽

Shigeru Hirota ◽

Junichi Iga ◽

...

Keyword(s):

Normal Pressure Hydrocephalus ◽

Older Patients ◽

Rating Scale ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Psychiatric Ward ◽

Drug Induced ◽

Timed Up And Go ◽

Older Inpatients ◽

Psychiatric Rating Scale

ABSTRACTBackground:The mean age of inpatients with schizophrenia has gradually increased in Japan and the risk of fracture in older schizophrenia patients is elevated. One possible cause may be idiopathic normal pressure hydrocephalus (iNPH). The present study aimed to evaluate the prevalence and symptoms of iNPH in older inpatients with schizophrenia.Methods:We prospectively examined older inpatients with schizophrenia (N = 21, mean age = 70.5 ± 5.9) in a psychiatric ward. We evaluated iNPH symptoms using the idiopathic Normal-Pressure Hydrocephalus Grading Scale (iNPHGS), Timed Up-and-Go test (TUG), Gait Status Scale (GSS), Mini-Mental State Examination (MMSE), and Neuropsychiatric Inventory (NPI). We also evaluated symptoms of schizophrenia using the Brief Psychiatric Rating Scale (BPRS) and Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). We conducted cerebrospinal fluid (CSF) tap tests for patients with possible-iNPH.Results:In total, three (14.3%) patients were diagnosed with possible iNPH: age, GS-Gait, GS-Cognition, TUG, 10-meter walking test, GSS, and DIEPSS were significantly increased in these compared to patients without iNPH; however, GS-Urine, MMSE, NPI, and BPRS did not differ significantly. Probable iNPH was diagnosed for two (9.5%) patients because of positive CSF tap tests.Conclusion:The prevalence of possible and probable iNPH in older patients with schizophrenia was much higher than that reported for older people without mental illness. Of the symptoms evaluated with the tests employed, only gait disturbances, particularly walking speed, distinguished schizophrenia patients with iNPH. These findings suggest that we should pay more attention to the possibility of iNPH in older patients with schizophrenia.

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