NPH Referral Request Form

Please verify that the following workup has been done to rule out alternative diagnoses for symptoms of idiopathic NPH:

• The patient has had normal UA, CBC, Comprehensive Metabolic Profile, TSH, B12, Calcium -ionized, Hemoglobin A1C, Homocysteine, Methylmalonic Acid and Vitamin D.
• A review of the patient’s medications has been done with no or minimized medications list on the Modified Beer’s List. (See Appendix A)
• There are no other obvious potential causes of gait abnormalities (acute illness, acute vertigo, orthostatic hypotension, acute gout, and rheumatologic disease, foot disorders and ulcers).
• The patient has been evaluated for and does not have sleep apnea or REM
  sleep behavior disorders.
• The patient has no significant history of alcohol or drug abuse.
• The patient has no significant history of major stroke.

Please verify stable medications and medical condition. If abnormal, we should defer the workup and formalized testing until these acute issues are resolved, since they can affect gait and cognitive status and the workup of the patient:

• The patient has not been hospitalized or had an ongoing acute illness over the past 60 days.
• The patient’s dose of the following medications has been stable over the last 60 days: acetyl cholinesterase inhibitors, e.g., Donepezil (Aricept), Rivastigmine (Exelon), Galantanine (Razadyne) or Memantine (Namenda).
• The patient’s dose of Parkinson’s medications has been stable for 60 days.
• The patient’s dose of antidepressants has been stable for 60 days.
• The patient has a normal PT/PTT.

Patients with a history of any of the following do not have idiopathic NPH, but may Patients with a history of any of the following do not have idiopathic NPH, but may benefit from surgery. We can help obtain an expedited referral to one of our neurosurgeons.

• Congenital hydrocephalus
• Traumatic brain injury
• Intracranial neurosurgical procedures (including ventriculostomy)
• Intraventricular hemorrhage
• Subarachnoid hemorrhage
• Meningitis
• Brain tumor
• Spinal disease

Please obtain the following:

• MRI brain without contrast
• MRI cervical spine without contrast
• If unable to have an MRI (e.g., shrapnel, pacemaker), please obtain a CT and CT c-spine.