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Gait Disorders in the Elderly Joseph H Gait Disorders in the Elderly Joseph H. Friedman, MD GA I T AND BALANCE BOTH DECL I NE W I TH disorders in the elderly.6 Base: the distance between the feet normal, or non-pathological aging. Gait My own experience, from talking to during walking. This should be and posture tend to become parkinsonian, patients and from reviewing doctor notes shoulder length or a little less and meaning “looks like Parkinson’s disease.”1,2 is that many patients do not have their should remain relatively stable This connotes a stooped posture, reduced walking evaluated during their routine from step to step. armswing, reduced stride length and a primary care physician (PCP) appoint- Speed: normal, slow or increased tendency towards a flat foot strike ments. In a study of hospitalized patients, Turning: people normally pivot when However, a large number of patho- often admitted after a fall, gait was not they turn. In Parkinson’s disease logical changes may develop contributing documented on the chart.7 The reasons and other gait disorders they may to this normal decline. Some of these for this are manifold, but I believe that take several steps. In addition, involve the nervous systems, central or two, which are virtually never discussed, some patients lose their balance peripheral, and some involve non-neuro- are: doctors have not been taught how to on turning or their feet freeze. logical systems which not neurologically evaluate gait and that most doctors lack Balance-assessed: with a pull from controlled. a vocabulary for gait, and therefore have behind (after warning the patient) It is obvious that gait difficulties and difficulty describing what they see. but also assessed by observing the imbalance contribute to reduced quality Walking requires the ability to stand, walking. Patients should walk in a of life. It is uncommon to meet a patient maintain position (keeping center of grav- straight line, and not veer. in a nursing home who walks normally. ity over the feet) and advance. The overall Romberg test: originally developed Gait impairment and the risk of falls is controlling mechanism is the brain, but, as a test for tabes dorsalis (tertiary one major contributing factor to nursing obviously, the feet, ankles, knees and syphilis of the spinal cord), this home placement. hips must be able to bear the weight; the is a general test of position sense, Falls are common in the elderly.3 muscles must be sufficiently strong. The with the eyes closed. Cerebellar, There are different definition for “fall,” inner ear must be able to determine the mild vestibular and sensory disor- but the World Health Organization direction of gravity’s pull. Binocular vision ders all may become evident. Its definition of a fall (E880-E888 in ICD 9 is important for judging distance and importance is less in the amount and W00-W19 in ICD 10) requires the compensating for other impaired sensory of sway than it is of the ability to person to come to rest “inadvertently” at a systems. The peripheral nerves must con- compensate for the sway, without lower level than intended. I consider trips vey information from the environment falling. and slips as different although possible in to the spinal cord, and then out to the indicators of a falling tendency. We all appropriate muscles at the appropriate Gait should be assessed initially by may slip on ice, or trip over a plug, but it time (“garbage in, garbage out”). And ag- observing the patient standing up from is an indicator of a problem if it is recur- ing affects each of these systems, often in a chair. In my office I use the same chair rent, suggesting a problem correcting the very unequal ways. Determining an exact each time, a firm bottom chair with arm- loss of balance. cause of a gait abnormality is sometimes rests. The patient is asked to attempt to Over 30% of community dwelling impossible, although identifying which stand without using the arms, but if un- people over 65 fall at least once each year4 systems contribute to the process is usually successful, with using the arms. It requires and falls were the leading cause of trau- not that difficult to determine. great strength to stand without using the matic death and morbidity in the elderly.4 arms, yet it requires very little leg strength The death rate from falls skyrockets with Vocabulary to stand or to walk if the patient can keep age, increasing from ten per 100,000 per Stand: ability of patient to stand up the knees locked. year for ages 65-74, to 147 per 100,000 from a chair and remain upright. What is a “normal” gait? My own in- per year for those over age 85.5 The fi- Posture: assess kyphosis, scoliosis, terpretation of normal is that it would not nancial costs alone are astronomical and lordosis, or other deviations from stand out as different if I saw the person increasing.3 normal walking on the street, or in a crowd. The claim that “falls among older Stride length: distance between steps, If possible, observe the patient walk adults are preventable,” is akin to stating which should be equal on the two into the examining room. If that appears that cigarette smoking or drug addiction sides, and appropriate for the normal and the history doesn’t suggest a or obesity is preventable. The correct distance and speed gait or balance problem, then record the statement is, and should be, “falls in the Arm swing and arm posture: as one gait exam as normal. If the gait is not elder can be reduced.” They cannot be foot advances the contralateral arm clearly normal then it should be more prevented, partly due to impaired cogni- swings. This should be symmetric formally evaluated. Ask the patient to tive function that often accompanies gait and appropriate for speed. walk ten to 15 feet. 84 MEDICINE & HEALTH/RHODE ISLAND Common neurological gait REFERENCES disorders in the elderly Rule # 1: 1. Critchley M. Neurologic changes in the aged. Parkinsonism: the most common, J Chronic Dis. 1956;3:459–72. if a patient 2. Bennett DA, Bckett LA, Muray Am, et al. and is characterized by a small Prevalence of parkinsonian signs and associated stride, stooped posture, slowness, requires an mortality in a community population of older normal base, reduced or absent people. N Eng J Med. 1996;334:71–6. armswing, absence of pivot dur- assistive device, 3. Michael YL, Whitlock EP, Lin JS, Fu R et al. Primary Care-Relevant Interventions to Prevent ing turning, poor balance. the reason should Falling in Older Adults: A Systematic Evidence cervical myelopathy: reduced stride, Review for the U.S. Preventive Services Task slow, excessively narrow base, ten- be recorded. Force. Ann Int Med. 2010;153:815–25. dency to walk on the balls of the 4. Centers for Disease Control and Prevention. Self reported falls and fall-related injuries among per- feet with a circumducting stride, Therapy comes after the diagnosis. sons aged over 65-United States, 2006.MMWR knees extended; armswing may The importance of physical therapy and Morb Mortal Wkly Rep. 2008;57;225–9. be reduced or normal daily exercise cannot be overstated. The 5. Centers for Disease Control and Prevention. ataxic: there are a variety of ataxic gaits. risk of falls must be reduced as far as Public health surveillance of 1990 injury control objectives for the nation. MMWR CDC Surveill The gait of alcohol intoxication is possible, but consonant with the recom- Summ. 1988;37:1–68. due to midline cerebellar degenera- mendation for walking as much daily 6. Buchman AS, Boyle PA, Leurgens SE, et al. tion, and looks like a “drunken” as possible. Home safety assessments by Cognitive function is associated with the gait, with a variable base and a visiting nurse service are paid for by development of mobility impairments in com- munity dwelling elders. Am J Ger Psychiatry. variable stride length, producing a Medicare and may recommend banis- 2011;19:571–80. lurching quality, with a loss of bal- ters, ramps, extra lighting, etc. Walking 7. Friedman JH, Skeete R, Fernandez H. Unrec- ance to either side. “Sensory ataxic devices should be forcefully encouraged, ognized parkinsonism in acute care medical especially to patients reluctant to use them patients receiving neurological consultations. J gait” is due to reduced propriocep- Geront A Biol Med Sci. 2003;58:94–5. tion, often combined with other either for vanity’s sake, or because of fear of becoming “dependent” on them. sensory reductions, to produce Further sources of information a wide based gait while the feet When elderly patients with gait Nutt JG, Horak FB, Bloem BR. Milestones in “slap” the ground, as if to increase problems are hospitalized for medical Gait, Balance, and Falling. Mov Disord. the stimulation. Bilateral vestibular problems they are often put at bedrest and 2011;26:1166–74. Viswanathan A, Sudarsky L. Balance and Gait dysfunction does not cause ver- rapidly decondition, sometime forever Problems in the Elderly. Handbk Clin Neurol. tigo but does cause an ataxic gait, losing their ability to walk. 2011;103:623–34. with a wide or variable base and a tendency to lose balance to either CONCLUD I NG SUGGEST I ONS Joseph H. Friedman, MD, is Direc- side. In ataxic gaits, the arms are Rule # 1: if a patient requires an tor of the Movement Disorders Program often abducted, to reduce the assistive device, the reason should be at Butler Hospital, and Professor in the movement of the center of gravity. recorded. Department of Neurology at the Warren Stride length is usually somewhat Rule # 2: falls should be charted and Alpert Medical School of Brown University.
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