Emergency Physicians' Ethical Duty to Patients with Undiagnosed Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) is a progressive yet potentially reversible neurological disorder affecting older adults, characterized by gait disturbance, urinary incontinence, and cognitive impairment. Unlike most dementias, iNPH responds to cerebrospinal fluid shunting, with early intervention yielding optimal outcomes.

To examine the ethical obligations of emergency physicians (EPs) in recognizing iNPH and to review practical screening methods applicable to emergency department (ED) settings.

Despite affecting approximately 2% to 5% of older adults presenting to U.S. EDs, iNPH remains profoundly underdiagnosed. Symptoms are frequently dismissed as normal aging or untreatable dementia. Recent randomized controlled trials demonstrate significant improvements in gait velocity and survival following shunt surgery, with the greatest benefits accruing from early intervention. EPs can identify possible iNPH through brief gait assessment, focused history, and standard neuroimaging. Recent advances in smartphone-based gait analysis and wearable sensor technology enable objective evaluation without specialized equipment. The principles of justice and beneficence mandate that older adults receive equitable access to treatments that can preserve cognition, mobility, and independence.

EDs should implement structured screening protocols, staff education, and referral pathways to ensure ethically sound practice. Recognizing possible iNPH represents both a clinical imperative and an ethical obligation.