Billy Joel, 76, said Friday that he is bowing out of his 2025 tour because he has been diagnosed with normal pressure hydrocephalus (NPH).
Joel said on Instagram that his brain condition had been exacerbated by his recent live performances, “leading to problems with hearing, vision, and balance.”
He was advised by his doctor to refrain from performing while he undergoes treatment and takes time to recover.
The “New York State of Mind” singer postponed several tour dates in March due to a “medical condition” that forced him to “undergo physical therapy under the supervision of his doctors” following an onstage fall in February.
“I’m sincerely sorry to disappoint our audience, and thank you for understanding,” Joel said Friday in response to the latest round of cancellations.
What is NPH?
NPH occurs when cerebrospinal fluid (CSF) builds up inside or around the brain, disrupting cognitive functioning.
CSF provides nutrients to and removes waste products from the brain while cushioning it and the spinal cord from force.
Typically, adults have 5 fluid ounces of CSF, with the body constantly producing, circulating and reabsorbing the fluid to keep that level constant.
But when the body fails to circulate or reabsorb CSF correctly, it can accumulate.
This buildup is usually gradual enough that the pressure inside the skull increases, but stays within normal range, and the fluid runs into the brain’s ventricles, which can hold some of the overflow.
Yet, if CSF keeps collecting, the brain begins to compress. If this compression lasts too long, permanent damage can occur.
NPH is most common in seniors, with the average age of diagnosis being 70.
NPH affects about 0.2% of people between the ages of 70 and 80 and about 6% of people over 80. NPH is very rare in people under 65, only affecting about 0.003%.
What are the symptoms?
NPH symptoms begin gradually and worsen over the course of three to six months. The three primary symptoms are known as Hakim’s triad and include:
- Urinary incontinence
- Difficulty walking
- Cognitive difficulties, including memory issues and emotional changes
Between 50% and 75% of people with NPH exhibit the three symptoms at the same time.
While symptoms of NPH are similar to those experienced by dementia patients, NPH is, in some cases, reversible.
What causes NPH?
There are two forms of NPH — primary (idiopathic) NPH and secondary NPH. Joel has not disclosed the form of NPH he has.
Primary NPH accounts for half of all cases and is attributed to age-related issues that compromise the body’s ability to make, circulate, and reabsorb CSF.
Evidence also suggests that NPH may be connected to degenerative brain conditions like Alzheimer’s disease and other forms of dementia. About 30% of people with NPH also have Alzheimer’s or a similar condition, according to Cleveland Clinic.
Secondary NPH is characterized by an underlying medical condition that affects the body’s ability to regulate CSF. These conditions include brain aneurysms and tumors, infections like encephalitis or meningitis, stroke and/or traumatic brain injuries.
How is NPH diagnosed?
NPH is a worsening condition that affects cognition, meaning many people don’t know they have it, making early detection difficult and early treatment critical.
Because of the overlap between symptoms of dementia and NPH, diagnosing NPH is challenging.
Doctors tend to eliminate other possibilities using a combination of methods, including spinal tap, physical and neurological examination and diagnostic imaging. MRI scans are the most important tool in NPH diagnosis.
How is NPH treated?
Primary NPH is typically treated with surgery and the implementation of a shunt. The shunt is characterized by two catheters that allow excess fluid to exit.
During surgery, a small hole is made in the skull, and the catheter passes through it, exiting downwards and allowing CSF to drain into the chest or abdomen, where it can be absorbed.
The type and efficacy of secondary NPH treatment depend on the underlying cause.
NPH Prognosis
Unlike other dementia-like conditions, NPH is often reversible, with a positive prognosis tied to early diagnosis and treatment.
The longer NPH goes undiagnosed, the more likely the increase in pressure will result in severe or permanent brain damage.
With treatment, the three tell-tale symptoms of NPH; mobility issues, cognitive difficulties, and urinary incontinence are likely to improve.
Factors that positively influence the treatment outcome include early diagnosis, NPH that improves after CSF is removed during a spinal tap, and cognitive issues that present after mobility and incontinence.
Conversely, delayed diagnosis, early onset cognitive difficulty, and the presence of other degenerative brain conditions make a positive prognosis less likely.
