Cognitive Therapy for NPH Patients

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Trish with her physical therapist, Tino.

By Trish Bogucki
Guest Blogger

I have normal pressure hydrocephalus (NPH) and have suffered from cognitive impairment. Unfortunately, I was so focused on my balance and gait issues that I did not seek treatment for my memory problems until after I underwent surgery and many months of Physical Therapy. In fact it was only when my neurosurgeon said that he didn’t need to see me for a year that I said “Wait a minute – I’m not fixed yet!”

I told him that I was having a lot of trouble remembering meetings at work, people’s names, tasks that I needed to do, passwords – the list went on and on. That’s when he told me about Cognitive Therapy and referred me to a local therapist, and my life definitely changed for the better. I was very fortunate to be referred to a terrific speech and cognitive therapist with whom I had an immediate rapport; I really enjoyed her energy, curiosity and optimism. What follows is a description of what cognitive therapy consisted of and some of the tips I have for others who might be in the same boat I was in. The first tip is probably the most important.

Tip #1: Seek help for cognitive issues as soon as you become aware of them. Ask your primary care physician, neurologist or neurosurgeon for a referral to a cognitive therapist or neuropsychologist for an evaluation if you have any issues with memory.

What is Cognitive Therapy (CT) all about? Like Physical Therapy (PT), it starts with an initial assessment meeting to determine the degree of impairment, whether Cognitive Therapy is needed, and the frequency of the therapy sessions. Also similar to PT, Cognitive Therapy is comprised of exercises and tools to help stimulate and strengthen – in this case your cognition is being strengthened and made more resilient.

Tip #2: Find a therapist you will enjoy seeing each week. You should look forward to your sessions and leave each one feeling more on top of things than when you went in.

What do you do at CT? At each appointment there are exercises done in the office: for example, memorizing simple flashcard images and being able to repeat a series of four, five or six images in order. Or looking at a picture of a complex scene and being able to answer questions about its contents. Another exercise involved reading a one-page newspaper article and then turning it over and being able to list facts contained in the article. At first you may be able to list only a few facts, but as you practice your list will grow.

Cognitive therapy is not limited to your office visits: there is homework for in between appointments. One recurring assignment was to work on brain games each day. There are several commercial web sites and mobile apps that feature brain training exercise designed by cognitive scientists. These sites/apps strengthen your cognitive skills in several areas: memory for sure, but also attention, flexibility, vocabulary, speed and problem solving. Some are free and some require an annual subscription fee.

Tip #3: Find a brain training website or app that you enjoy (and can afford) and challenge yourself to use it daily for up to a month. If you’re not hooked after a month then look for a different app, but find one that you like.

Cognitive therapy isn’t all fun and games. Your therapist may ask you to discuss any issues you faced since your last visit and offer strategies for avoiding “meltdowns” in the future. Some of the strategies are simple – like putting your keys in a bowl by the door whenever you come home so you are not searching madly for them when it’s time to go. One strategy that works well for many is the “bag for every occasion” approach: designate a tote bag for work, another for class, another for therapy/gym, etc. Put things you will need in the bag when you think of it instead of waiting till you’re running out the door.

Tip #4: Act on a thought (like putting things in one of your bags) when you have it instead of trying to remember it later. If you’re not in a place where that’s feasible then write it down in a notebook or smartphone that you keep with you.

Other strategies involve technology – like making regular use of the calendar function on your phone or computer to remind you of appointments or tasks and then making it a regular practice to check your calendar at least every morning, afternoon and evening. Another is keeping a small notebook or a smartphone with you for capturing To Dos for later. You may not be able to cure your memory loss, but these strategies will help you deal with it. There are several components to cognition: memory for sure, but also attention, flexibility, vocabulary, speed and problem solving. I learned that a lot of the issues attributed to poor memory are actually caused by a lack of attention.

Tip #5: Find brain exercises and games that work on attention as well as memory.

How do you know when you are done with therapy? Once you stop seeing dramatic improvement after each visit and start seeing more consistent performance then it may be time to end formal therapy. Of course sometimes your insurance runs out first, but that’s something you should discuss up front with your therapist.

Tip #6: Plan how long your therapy can/should last with your therapist and develop a list of exercises and strategies that you will employ after you’re done seeing the therapist.

I recently attended a talk at a local library on cognitive health for seniors and was happy to get reinforcement of the importance of keeping your brain challenged. They distributed a long list of websites and apps that offer brain exercises and they stressed the importance of trying new learning challenges and not relying on just one or two activities.

Tip #7: Don’t stop working on your cognition! Take a course at your local high school or community college or try a new hobby – these can be fun learning experiences that will help challenge your cognition (as well as opportunities to meet new people).

It’s important for all of us as we get older to keep our brains challenged with learning new skills, but I think NPH patients may not need so much convincing of that. Cognitive therapy improved my quality of life considerably, and I am very grateful to my wonderful therapist for all the strategies she taught me. I wish you similar success in your therapy!


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This page is designed to provide helpful information on the subjects discussed. It is not intended as a substitute for treatment advice from a medical professional. For diagnosis or treatment of any medical condition, consult your doctor.

23 Comments for : Cognitive Therapy for NPH Patients
    • Susi Harison
    • December 30, 2018

    My Aunt has been suffering with mobility and cognitive issues for a year and a half. A neurologist has suggested that she has hydrocephalus. On top of this she has stage 4 breast cancer with mets to her bones. She is 77 years old. She has just recently been admitted to a longterm care facility. While I am happy that there is hope for a recovery, I’m concerned because she feels that this will be a miracle cure snd she will walk out after shunt implant and go home….is this realistic??? Just wondering where we are going here….Thanx…

    • margie
    • July 8, 2017

    Hello I am a care taker of my mother who has NPH and was fitted with shunt few months ago. I am trying to find out any info on not only the memory loss part of this but if there are other ways that effect the mentality of some one with NPH; such as fits of anger in relatively calm person before diagnosis. My mother always had the patients of a saint until she was diagnosed, yet has become extreme since surgery.

      • Trish Bogucki
      • July 24, 2017

      Hi Margie: You should ask your mother’s doctor what might be causing her fits of anger and whether therapy might help. In my case I have never had the patience of a saint and I would get frustrated or angry when I fell or when I forgot something I used to know well. My cognitive therapist routinely asked me if I had had any meltdowns in the preceding week and we would discuss strategies for preventing them. That helped me quite a lot. I’ve also read that that type of counseling may be provided by a neuropsychologist, so do check with the doctor to see if any of these professionals might be of assistance. Best of luck, Trish

    • Cathy Razor
    • June 15, 2017

    Before my shunt was installed last October because of obstructive hydrocephalus, I shuffled and the worse things were that I had a very hard time getting up and down froma chair and had urinary incontinence issues. After the VP sunt was installed, almost all of my symptoms have gone away. My double vision improved to the extent that I needed new glasses. My neurosurgeon told me that improvement should continue for one year. My balance is still a little off but my neurosurgeon says that is the result of some myelopathy and stenosis in my neck, for which I am having another surgery in July. My fine motor skills are still off and some days my handwriting is illegible, so thank God for the computer! My dad had Parkinsons SNP and I was afraid that that is what I originally had but after my surgery to install the shunt I found out that the colloid cyst in my third ventricle may run in our family as one of my cousins also had one. That is what caused my hydrocephalus.

    • Reply

      Cathy–I also have persisting balance and gait problems due to cervical myelopathy and stenosis. I’m wondering if that’s just a coincidence to have hydro too, or if theres’s a physical or genetic association.

    • Denise Hunt
    • June 13, 2017

    Hi, thank you for an interesting article and comments. I am supporting my 82year old Mum who has NPH. I hadn’t thought about CT and her GP hasn’t mentioned it either, will be discussing on our next visit.

      • Trish Bogucki
      • June 27, 2017

      Hello Denise: If your mom’s doctor does prescribe CT I hope it helps her. It was such a positive experience for me and a year later I continue to do my homework each day. It all helps!

  1. Reply

    Is it possible to get a copy of Patients Guide to Normal Hydrocephalus? I live in Ireland and have been suffering from the condition for the last four years. Any information would be greatly appreciated.

      • Trish Bogucki
      • July 4, 2017

      Hello Eamon: I requested that an information packet be sent to you, and I’ve been told it has been. I’m sorry to hear that you’ve been struggling with NPH for four years; that’s about how long I’ve had it. Has your doctor recommended shunt surgery? When mine did I sought a second opinion and that doctor told me that shunt surgery was the only effective treatment for my NPH.
      I had shunt surgery two years ago. It helped but didn’t do the whole job – I needed physical therapy and some cognitive therapy as well. But now I am very glad I did all that – I can walk and swim and do my household chores and take Step Class again – just like I did before NPH. I hope you get the help you need!
      All the best, Trish

        • Jane Phillips
        • December 17, 2018

        Trish, I noticed in one of your postings that you can swim again. One of my earliest symptoms before I was diagnosed with NPH was the feeling that my legs were filled with lead. I could no longer walk distances unlike being able to go on hikes in my younger days. I also discovered that my legs wouldn’t let me kick in the swimming pool. They sank like lead weights. Since I have had my shunt I have not tried swimming again. I am wondering if anyone else has had this “lead legs” experience.

    • Peter Lower
    • June 13, 2017

    Hello: I have been diagnosed with NPH after falling and cracking my head hard on a cement floor. This happened five months ago. My balance has suffered a lot. My cognitive functioning not as much. I have some changes in short-term memory but generally can still function at a reasonably high level. The fall broke my neck so there’s been lots of pain and I’ve just removed the neck brace after my neuro surgeon declared the occipital condyle fracture healed. I would very much like to improve my balance and gait which is unsteady and have heard good things about shunt surgery. Improvement rates seem to be between 60 and 80 percent.

    I’m also aware of the possible complications of shunt surgery.
    I have confidence in my neuro-surgeon who works out of Sunnybrook Hospital in Toronto.

    I’ve said yes to the surgery but have some reservations. What I have now I could live with. I’d hate to make things worse.

    Any advice would be appreciated.

    Cheers, Peter Lower

      • Trish Bogucki
      • July 1, 2017

      Hello Peter: You have been through a lot already; I can understand your hesitation. Does your doctor recommend shunt surgery as the best next step for you? When mine first did, I was not in favor of it. I sought a second opinion and that doctor confirmed that shunt surgery was the only realistic option in my case. But I know every case is different.

      While I was resisting surgery my neurologist performed a spinal tap and I saw temporary improvement after that. That improvement supported the shunt surgery recommendation, and it reminded me what it was like to walk normally again. I went ahead and had the shunt surgery and then did physical therapy to regain my walking and balance. There was a special treadmill at PT which helped improve my walking a lot.

      It’s great that you have confidence in your neurosurgeon, but you could still seek a second opinion on shunt surgery. Have you discussed a spinal tap or physical therapy with your doctors? I hope you find a treatment that helps!

  2. Reply

    Thank you for this. They look like good suggestions for anyone aging or otherwise experiencing memory loss.

      • Jim Filippini
      • July 24, 2017

      I was shunted at the age of 46 for NPH. I’m 68, and each day since surgery is (almost ) measurably better. The incontinence stopped in it’s tracks while I was still on the surgery table–a miracle, if you ask me…my 95 year old mother has (what looks to me) all the symptoms of NPH, but we can’t bring ourselves to suggest surgery to a 95 year old. Thank you for sharing!

        • Trish Bogucki
        • July 30, 2017

        Hello Jim: I can understand not wanting to subject a 95-year-old to brain surgery. Has her doctor offered any other options? My neurologist performed a lumbar puncture while I was resisting surgery and it provided some relief, but in my case it was very temporary.
        I am so glad your shunt surgery was successful and that you saw some immediate improvements and continue to see additional improvements. My progress was slower – possibly because I waited so long before seeking help and there was so much fluid in my soggy brain. But like you I continue to see improvements and rejoice in them! Today’s was carrying a full bucket of water up from the basement dehumidifier without spilling a drop. There’s usually a little trail of splashes in my wake, but not today! Best of luck to you and your mom.

    • Joy Rogers
    • June 13, 2017

    How can I access such therapy for NPH? I live in southwest Florida. I’ve known I have NPH since January and still don’t have either surgery or cognitive therapy. They’ve ruled out Parkinson’s, MS, etc. I don’t seem to have several of the problems ( memory and urinary incontinence) that they think are diagnostic–so they keep hedging and delaying. I would so love to have at least better balance!

      • Trish Bogucki
      • June 27, 2017

      Joy: My neurologist sent me for an MRI which confirmed that I have NPH. She showed me the images and the areas of fluid that should not have been there were quite obvious. She tried several spinal taps to remove the fluid but they had only a temporary effect. I had shunt surgery shortly after being diagnosed and started physical therapy a few weeks later to get my walking back and improve my balance. Cognitive therapy followed several months after that but I wish I could have started it sooner – it helped me so much. My cognitive therapist was in the speech therapy department of our local hospital – you could see if a hospital near you has a similar group.

        • Larry
        • January 31, 2018


        When I was diagnosed with NPH (at age 66), the people working for my surgeon (I think they were nurse practitioners) did a spinal tap. They explained that this was only to confirm the disagnosis and to see if the NPH was indeed resposible for my walking problems. When the tap removed some CSF from my brain, my gait improved, which reinforced the idea that the shunt implantation would be the right treatment and alleviate my gait difficulty. The spinal tap was not meant to be a solution for the NPH.

        I’m writing this because I think some of the commenters have assumed that a spinal tap is being proposed as a fix for NPH, which I don’t think is the case (Someone please correct me if I’m mistaken.)

  3. Reply

    Thank you. I had the surgery 20 years ago at the age of 60 and had to do my own brain recovery therapy. It is nice to know that there is help for folks now.

  4. Reply

    Trying to find out those with NPH and imbalance, I’d like to find out if your imbalance comes from the shuffling of your legs that feel like weights or stuck to floor or do you feel you body is rocking back and forth while you are actually standing still?

      • Trish Bogucki
      • May 31, 2017

      Hello Susan: In my case my balance issues usually felt like dizziness – the world was swimming around me. Sometimes the dizziness was so bad I fell over – e.g., when straightening up from bending over. On one occasion I cracked two ribs when I fell backwards. My balance improved some after shunt surgery and now has improved a lot from all the balance training I’ve done.

        • Jackie Blanchard
        • June 9, 2018

        I don’t know if you are still following posts to your “blog” or whatever it might be called, but thank you so much for the cognitive therapy and other information you’ve shared. My sister has NPH and had a shunt operation two years ago. There was an immediate improvement but a brain bleed resulted in a year-plus of delay in getting back on track. I would love to correspond with you directly on a couple of questions (won’t be a pest!) if possible.

        • Reply

          Jackie: Sorry for the delay – I just saw your comment. I’d be happy to correspond with you via email or phone – you can call HA and ask to be put in touch with me via the Peer Support program. I am always happy to share my experiences with other patients and their family members. Hope to talk with you soon!

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