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Gait Disorders: Search for Multiple Causes

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Gait Disorders: Search for Multiple Causes REVIEW NEIL B. ALEXANDER, MD ALLON GOLDBERG, PhD Institute of Gerontology; Division of Geriatric Institute of Gerontology; Division of Geriatric Medicine, Department of Internal Medicine, Medicine, Department of Internal Medicine, University of Michigan; Ann Arbor Veterans University of Michigan; Ann Arbor Veterans Health Care System, Geriatric Research Health Care System, Geriatric Research Education and Clinical Center, Ann Arbor, MI Education and Clinical Center, Ann Arbor, MI Gait disorders: Search for multiple causes ■ ABSTRACT AIT DISORDERS IN ELDERLY patients often G lead to falls and disability. They are a Gait disorders predict functional decline in older adults. strong predictor of functional decline. They are often the result of multiple causes, so a full More often than not, a gait disorder rep- assessment should consider different sensorimotor levels resents the combined effects of more than one and should include a focused physical examination and coexisting condition, so the evaluation should evaluation of functional performance. Exercise and take comorbidities into consideration and medical and surgical interventions are effective and can should include assessment of different levels of reduce the degree of gait disorder, but usually not sensorimotor deficits. without some residual impairment. Orthoses and mobility In this article, we review the prevalence, aids are also important interventions to consider. impact, and causes of gait disorders in the elderly. We also outline appropriate clinical ■ assessments and interventions known to KEY POINTS reduce the severity of gait disorders. In assessing gait disorders, it is helpful to categorize the ■ problem according to the level of the sensorimotor INCIDENCE AND PREVALENCE deficit. OF GAIT DISORDERS At least 20% of noninstitutionalized older Dementia and depression contribute to gait disorder but adults admit having trouble walking or require may not be the sole causes. the assistance of another person or special equipment to walk.1 Limitations in walking Acute gait disorder may be the presenting feature of also increase with age. acute systemic decompensation in an older adult, and it In some samples of noninstitutionalized warrants evaluation for myocardial infarction or sepsis. adults age 85 and older, the prevalence of lim- itation in walking can be over 54%.1 While A formal neurologic assessment is critical and should age-related changes such as gait speed are include strength and tone, sensation (including most apparent after age 75 or 80, most gait dis- proprioception), coordination (including cerebellar orders appear in connection with underlying function), standing, and gait. Vision screening, at least for diseases, particularly as disease severity increases. For example, age over 85, three or acuity, is essential. more chronic conditions, and the occurrence of stroke, hip fracture, or cancer predict “cata- The Timed Up and Go (TUG) test is a simple tool for strophic” loss of walking ability.2 assessing stability. A fall or any difficulty or unsteadiness during the TUG test requires a more extensive evaluation What is normal, and what is not? of gait and fall risk factors. Determining that a gait is “disordered” can be difficult, as there are no clearly accepted stan- dards as to what is a “normal” gait in older 586 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 7 JULY 2005 Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. adults. Some believe a slowed gait is a disor- lar dementia.6 Of note, at baseline, those with dered gait, and others believe that any aesthet- abnormal gait may not have met criteria for ic abnormality—eg, deviation in smoothness, dementia but already had abnormalities in symmetry, and synchrony of movement pat- neuropsychological function, such as visual- terns—constitutes a gait disorder. However, a perceptual processing and language skills. slowed or aesthetically abnormal gait may in Gait disorders with no apparent cause fact provide the older adult with a safe gait pat- (“idiopathic” or “senile” gait disorder) are tern that helps maintain independence. associated with a higher death rate, primarily from cardiovascular causes; these cardiovascu- Gait disorders tend lar causes are likely linked to concomitant and to be multifactorial, progressive possibly undetected cerebrovascular disease.7 In older patients, attributing a gait disorder to a single disease is particularly difficult—and is ■ CONDITIONS THAT CONTRIBUTE often not advisable—because many different TO GAIT DISORDERS conditions can result in similar gait abnormal- ities.3 Disordered gait, defined as a gait that is Recent longitudinal studies suggest that slowed, aesthetically abnormal, or both, is not certain gait-related mobility disorders progress necessarily an inevitable consequence of aging with age and that this progression is associat- but rather a reflection of the increased preva- ed with disease and death. When measured by lence and severity of age-associated diseases.8 the Unified Parkinson Disease Rating Scale These underlying diseases, neurologic and (UPDRS), which includes abnormalities in nonneurologic, contribute to disordered gait. rising from a chair and turning, gait and pos- Elderly patients usually have more than one tural disorders increased in most (79%) of a condition contributing to their gait disorder. nondemented sample of Catholic clergy with- When asked what makes walking difficult, out clinical Parkinson disease (mean age 75) patients most often cite pain, stiffness, dizzi- followed for up to 7 years in a prospective ness, numbness, weakness, and sensations of cohort study.4 This increase was more com- abnormal movement.9 Conditions seen in the Declining gait mon in older subjects and was associated with primary care setting that can contribute to gait speed predicts a higher death rate. disorders include degenerative joint disease, These observations raise several questions. acquired musculoskeletal deformities, inter- cognitive The UPDRS may be more appropriate for mittent claudication, impairments following decline in patients known to have Parkinson disease, but orthopedic surgery and stroke, and postural an increased UPDRS score may represent hypotension.9 healthy older increased parkinsonian signs with age in In a group of community-dwelling adults adults patients without a diagnosis of parkinsonism, over age 88, joint pain was by far the most as well as an increase in associated disease and common contributor, followed by stroke and inactivity. It is also unclear whether subjects visual loss.8 in this cohort developed other overt neurolog- The diagnoses found in a neurological ic disease, dementia, or both. For example, referral population were primarily neurologi- declining gait speed is one of the factors that cally oriented10,11 and included frontal gait can independently predict cognitive decline disorders (usually related to normal-pressure prospectively in healthy older adults.5 hydrocephalus and cerebrovascular processes), Cerebrovascular disease, both subclinical sensory disorders (also involving vestibular and clinically evident, is increasingly recog- and visual function), myelopathy, previously nized as a major contributor to gait disorders undiagnosed Parkinson disease or parkinson- (see discussion of assessment below). Non- ian syndromes, and cerebellar disease. demented patients with clinically abnormal Conditions that cause severe gait impair- gait (particularly unsteady, frontal, or hemi- ment, such as hemiplegia and severe hip or paretic gait) who are followed for approxi- knee disease, are often not mentioned in these mately 7 years are at higher risk of developing neurologic referral populations. Thus, many non-Alzheimer dementia, particularly vascu- gait disorders, particularly those that are clas- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 7 JULY 2005 589 Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. GAIT DISORDERS ALEXANDER AND GOLDBERG sic and discrete (eg, related to stroke and ating steps, and a tendency toward falling. osteoarthritis) and those that are mild or These and other nonspecific findings, such as related to irreversible disease (such as vascular the inability to perform tandem gait, are simi- dementia), are presumably diagnosed in a pri- lar to gait patterns found in a number of other mary care setting and treated without referral diseases, and yet the clinical abnormalities are to a neurologist. Dementia and fear of falling insufficient to make a specific diagnosis. This also contribute to gait disorders. “disorder” may be a precursor to a still asymp- Less common contributors to gait disor- tomatic disease (eg, related to subtle extrapyra- ders include metabolic disorders related to midal signs) and is likely to appear with con- renal or hepatic disease, tumors of the central current, progressive cognitive impairment (eg, nervous system, subdural hematoma, depres- Alzheimer disease or vascular dementia).21 sion, and psychotropic medications. Case While the concept of senile gait disorder reports also document reversible gait disorders reflects the multifactorial nature of gait disor- due to clinically overt hypothyroidism or der, we feel it is generally not useful in label- hyperthyroidism and deficiency of vitamin ing gait disorders in older adults. 3 B12 and folate. ■ APPROACH TO ASSESSMENT ■ DISEASE-RELATED FACTORS THAT AFFECT GAIT A potentially
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