By: Kathy Hubbard
In May, Billy Joel announced that he was cancelling upcoming concert performances because he has been diagnosed with normal pressure hydrocephalus (NPH). In an interview with Bill Maher he said, “I feel fine. My balance sucks. It’s like being on a boat.”
I’ll let the Hydrocephalus Association explain what NPH is: “Normal pressure hydrocephalus is when there is a build-up of cerebrospinal fluid (CSF) in an area in the center of the brain called (ventricles). This causes the ventricles to become enlarged, sometimes with little or no increase in intracranial pressure (ICP).”
“Under normal circumstances, our body produces an appropriate amount of CSF each day, and any extra fluid is reabsorbed back into the body. However, for people with NPH, the CSF is produced in regular amounts but fails to be absorbed properly, resulting in its accumulation. As the fluid builds up, the ventricles enlarge or swell to accommodate the increase in volume of fluid. This enlargement puts pressure on the surrounding brain tissues. People with NPH can have varying fluctuations in CSF pressure, ranging from high to low within a particular set of parameters.”
The cause is unknown, and it’s often misdiagnosed as Alzheimer’s or Parkinson’s disease, or it is thought to be a result of a stroke or other neurodegenerative conditions. Sometimes it’s mistakenly attributed to “normal aging” because it often mimics and occurs about the same time as age related conditions. It’s estimated that 30 percent of people with NPH also have Alzheimer’s disease or a similar degenerative brain disease.
Cleveland Clinic explains that there are two forms of NPH, and they happen at equal rates. They are primary (idiopathic) NPH, which means it happens for unknown reasons and secondary NPH which indicates that it’s caused by another medical condition, such as a head injury, cranial surgery, tumor or cyst, meningitis and other brain infections.
The Hydrocephalus Association adds, “It is also understood that some people are born with hydrocephalus but don’t develop symptoms until late in life. They may be completely unimpaired until their hydrocephalus is detected through CT or MRI scans performed for unrelated reasons. Currently, it’s unknown what percentage of asymptomatic congenital hydrocephalus patients will eventually develop symptoms of NPH.”
Symptoms are typically referred to as Hakim’s triad for the physician that identified NPH. They include gait issues, urinary incontinence and cognitive difficulties. Most commonly NPH affects people over 65, becoming more and more common the older one gets. The average onset is around age 70. Joel is 76.
The Alzheimer’s Association says that Joel’s description of how NPH has affected his gait is typical. They say that NPH causes “difficulty walking that’s sometimes compared to the way a person walks ‘on a boat,’ with the body bent forward, legs held wide apart and feet moving as if they’re ‘glued to the deck.’”
They also said that other symptoms include “mild dementia that involves loss of interest in daily activities, forgetfulness, difficulty completing routine tasks and short-term memory loss; decline in thinking skills that includes overall slowing of thought processes, apathy, impaired planning and decision-making, reduced concentration, and changes in personality and behavior, and loss of bladder control, which tends to appear somewhat later in the disease than difficulty walking and cognitive decline.”
Alzheimer’s Association quoted a Mayo Clinic study of 41 adults with suspected normal pressure hydrocephalus. “All had difficulty walking, 30 experienced cognitive decline, and 14 reported loss of bladder control. Only 12 of the 41 had all three symptoms.”
To confirm a diagnosis, your healthcare provider will perform a physical and neurological exam, order diagnostic imaging, primarily an MRI, and most likely will do a spinal tap. Cleveland Clinic says that depending on your symptoms, your PCP might recommend other tests as well.
“Overall, NPH is usually a treatable condition,” Cleveland says. “The treatment approach varies depending on whether it’s primary/idiopathic or secondary NPH. Unlike most brain-related conditions, treating NPH rarely involves medications. That’s because NPH doesn’t respond to medications (though medications may treat some symptoms related to NPH).”
As with just about every other disease and condition I write about, early detection will result in the best outcomes. One can assume Billy Joel has the best medical team and hopefully he knows that he’s the star of that team.
Kathy Hubbard is a member of the Bonner General Health Foundation Advisory Council. She can be reached at kathyleehubbard@yahoo.com. This article was written for publication in the Bonner County Daily Bee on August 6, 2025.
