Gait Disturbances in Old Age

Classification, Diagnosis, and Treatment From a Neurological Perspective

Background: Gait disturbances are among the more common symptoms in the elderly. Reduced mobility markedly impairs quality of life, and the associated falls increase morbidity and mortality.
Methods: Review of the literature based on a selective search (PubMed) on the terms “gait,” “gait disorder,” “locomotion,” “elderly,” “geriatric” and “ageing” (2000–11/2009) and the findings of the authors’ own studies on gait changes in old age and on the functional brain imaging of gait control.
Results: Gait disturbances in the elderly are often of multifactorial origin. The relevant pathogenetic factors include sensory deficits (visual, vestibular, somatosensory), neurodegenerative processes (cortical, extrapyramidal motor, cerebellar), toxic factors (medications, alcohol), and anxiety (primary or concerning falls). A clinically oriented classification of gait disorders is proposed, which, on the basis of the characterization of gait and the accompanying clinical findings, enables identification of the etiological factors and points the way to rational therapy. Current research topics in the study of gait disturbances are also discussed, including quantitative gait analysis, interactions between locomotion and cognition (dual tasking), and functional imaging approaches.
Conclusions: The evaluation of elderly patients whose chief complaint is a gait disturbance should be directed toward the identification of specific deficits. This is the prerequisite for rational therapy, even when the problem is of multifactorial origin. The preservation of mobility is important in itself, and also because the ability to walk is closely correlated with cognitive performance.

Gait disturbances are a common medical problem in old age. Among the patients of a hospital department of acute neurology, old age is the most important risk factor for a gait disturbance (1). A variety of diseases can cause gait disturbances; some, like Parkinson’s disease, have well-established treatments according to the principles of evidence-based medicine, while for others, like -cerebrovascular gait disturbance, too little evidence is available to support any particular form of treatment. A population-based study has shown a 35% prevalence of gait disorders among persons over age 70 (2). 85% of 60-year-olds still walk normally, but only 20% of 85-year-olds do (3). The latter fact also implies, however, that gait disturbances are not an inevitable accompaniment of old age. Problems of balance and gait are associated with immobility and falls, which markedly impair the quality of life (4). About 30% of persons over age 65 living at home fall at least once per year; among nursing home residents, the corresponding figure is about 50% (5). Mobility is often restricted still further by the fear of falling (6). Patients visiting their family physician because of gait disturbances complain most often of pain, joint stiffness, numbness, weakness, and an abnormal pattern of gait (7).

The learning goals for readers of this article are

• to know the different methods used in the diagnostic assessment of gait disturbances,
• to be able to identify the factors that contribute to the (multifactorial) gait disturbances of old age, and
• to be acquainted with the effective treatments that are available for certain types of gait disturbance.

This article is based on a selective review of the literature in the PubMed database. The clinical overview also incorporates the authors’ own findings on age-related changes in gait and on the functional cerebral imaging of gait control.

The definition of gait disturbances in old age
Walking is one of the more frequently performed sensorimotor tasks in everyday life. It relies on a complex, simultaneous interaction of the motor system, sensory control, and cognitive functions. The diagnostic assessment of gait disturbances in old age requires a clear distinction of pathological findings from the normal, physiological changes of aging. Spontaneous walking speed normally decreases by about 1% per year from age 60 onward (8), and the observed decline of maximum walking speed is even greater (Figure 1 gif ppt). On the other hand, a gait disturbance in old age is said to be present when the patient walks even more slowly than expected for age, or when there are qualitative abnormalities of locomotion, such as disturbances of the initiation of gait or of balance while walking (9). The patient’s gait should be observed in standardized fashion, and the findings should be compared to age-specific norms. Gait disturbances in old age should be clinically classified in purely descriptive terms at first; deficits should be recorded as deviations of the main quantitative parameters of gait—speed, step size, and breadth of stance—from the corresponding age-specific norms. Blanket terms such as “senile gait disturbance” should be avoided, because specific treatment cannot be provided if the relevant deficits underlying the gait disturbance have not been identified.

Overview of the physiology of gait control
The rhythmic movement pattern of human gait is established at the level of the spinal cord, where so-called central pattern generators, i.e., coordinated groups of interneurons, control the alternating activation of agonist and antagonist muscles during the gait cycle (e1, e2). The existence of autonomous spinal rhythm generators was postulated about 100 years ago, when Thomas Graham Brown demonstrated the persistence of locomotor movements in cats after decerebration, i.e., complete transection of the brainstem. The existence of rhythm generators in man as well is supported by the presence of spinal locomotor movements in paraplegic patients, and by the presence of coordinated movements in all four limbs (arms as well as legs) during bipedal gait (e3, e4). It remains unknown, however, how autonomously the spinal generators control normal human gait; supraspinal control is presumably more important for human, bipedal gait than it is for the quadrupedal gait of the cat. The centers in the spinal cord interact with sensory systems (in particular, the somatosensory afferent pathways) and are under the control of locomotor regions in the brain that enable the initiation of gait, standing still, changes of speed and direction, and reactions to interference with gait. The cerebral control network for gait is schematically shown in Figure 2 (jpg ppt). Gait is mainly controlled by the premotor and motor areas of the frontal cortex; these areas project fibers to the basal ganglia and onward to the locomotor centers of the brainstem and cerebellum, which, in turn, control the spinal generators. Functional imaging studies have revealed the regions in the human brain that are important for the control of gait (10, 11).

Classification of gait disturbances
Nutt and Marsden’s proposed classification of gait disturbances into higher-, intermediate-, and lower-level disturbances is in wide use (12). In this scheme, lower-level disturbances involve the peripheral effector organs of locomotion (e.g., arthritis, myopathy, and polyneuropathy); intermediate-level disturbances involve the efferent and afferent sensorimotor pathways of the central nervous system (e.g., paresis after stroke, extrapyramidal manifestations in Parkinson’s disease, and incoordination due to cerebellar dysfunction); and higher-level disturbances involve a deficit of the cortical control of gait (e.g., frontal, anxiety-related, and psychogenic gait disorders). This three-level classification, however, provides only limited help in the clinical setting. The authors prefer to classify gait disorders on the basis of the clinical findings alone, as proposed by Snijders et al. (13), because such a classification is easier to apply in practice (Figure 3 gif ppt). Clinical classification is the first of several well-defined steps toward the establishment of a diagnosis. The clinical examination suffices for an initial classification that resists premature anatomical, pathological, or etiological inferences, yet nonetheless points the way to further diagnostic evaluation.

History, physical examination, and additional diagnostic tests
History
History-taking in elderly patients with gait disturbances enables the physician to assess certain factors that would not be evident from the physical examination alone; some important ones are listed in Table 1 (gif ppt). Medications, in particular, often cause dizziness, fluctuating gait unsteadiness, and falls. It can also be very helpful to know what factors tend to precipitate and/or exacerbate the gait disturbance; such information might, for example, reveal that anxiety is a component of the problem.

Clinical presentation
The common types of abnormal gait, whose recognition is the first step in clinical classification (Figure 3), are summarized in Table 2 (gif ppt). The following types are particularly common among elderly patients seen by neurologists:

• sensory (e.g., polyneuropathy),
• hypokinetic (e.g., Parkinson’s disease),
• ataxic (e.g., degenerative cerebellar atrophy),
• anxiety-related (e.g., fear of falling).

Antalgic gait disturbances (e.g., arthritis) and paretic gait disturbances (e.g., radiculopathy after disk herniation) account for a considerable percentage of the gait disturbances seen by general practitioners, orthopedists, and neurologists. Spastic, dyskinetic, and psychogenic gait disturbances are found in old age, but no more commonly than at any other time of life.

The patient’s gait can be analyzed in a number of ways. The simplest is clinical observation of the patient, who is asked to walk a certain distance with the eyes open and closed, as well as during distraction and/or performance of a cognitive task. The examiner should note the patient’s posture, speed of gait, any asymmetry, the width and length of steps, the height of the feet above the ground in each step, the variability of steps, disequilibrium with gait deviation and/or tendency to fall, and the accompanying arm swing. Experienced examiners can usually classify the gait disturbance correctly by observation alone (Table 2).

Alongside various tests of stance and gait (walking with the eyes closed, tandem stance/gait, standing on one leg, heel and toe walking), the clinical assessment of gait disturbances in old age also includes the evaluation of sensory deficits (visual, vestibular, somatosensory). Further important components are a complete neurological examination (including eye movements and the motor function of the limbs), an assessment of the active and passive ranges of motion of the large joints, and a general medical examination.

Timed tests, such as the timed up-and-go test, involve measuring the time it takes for the patient to carry out a given motor sequence. Such tests are commonly used, easy to perform, and thus useful for longitudinal assessment (14). They yield numerical parameters of mobility beyond the simple ability to walk. In the timed up-and-go test, the patient sits on a standard armchair. When the signal is given, he or she stands up, walks three meters, turns around, walks back to the chair, and sits down again. The time it takes to do this is recorded.

The pull test of righting reflexes provides a very useful index of the risk of falling. This test exists in many variants (15). Most commonly, the examiner stands behind the patient and exerts a sudden, brief backward pull on the shoulders. The patient is warned beforehand of what is going to happen; the eyes are open, and the feet are a comfortable distance apart (16).

The examiner assesses the patient’s ability to respond to this interference by rapidly correcting stance and/or by taking a step backward. If a disease is present that impairs the righting reflexes (e.g., progressive supranuclear palsy), the patient will respond inadequately and will have to be caught, no matter whether the perturbation was expected.

Additional diagnostic tests
Ancillary tests are used to provide specific confirmation for the provisional diagnosis that has already been formulated on the basis of the history and physical examination, and they should thus be performed selectively. Sensory testing is often a useful component of basic neurological assessment in elderly patients with gait disturbances. It includes testing of the visual acuity and fields (visual testing), the head-impulse test for the vestibulo-ocular reflex and caloric testing for vestibular inner ear function (vestibular testing), and measurement of nerve conduction velocities (somatosensory testing). The type and extent of neuroimaging studies that are required depend on the abnormalities disclosed by the clinical assessment.

Newer diagnostic procedures
Dual-tasking ability
The reciprocal interaction of cognitive function and gait is a fascinating area of research, with practical clinical implications. Tests of dual-tasking ability are relatively easy to integrate in the clinical examination. The patient should be asked to walk while performing either a cognitive task (e.g., backward calculations, listing words in a particular category) or a motor task (e.g., carrying an object or performing a specific movement with the hands). The “stop walking while talking” sign is a typical finding when the interaction between gait and cognition is disturbed (17) and can also be used as a clinical test (18, 19). Worsening gait during dual tasking is characteristic of gait disturbances whose cause lies at the cortical or subcortical level (e.g., neurodegenerative dementia, vascular gait disturbances), as well as of parkinsonism. Many patients show a paradoxical reversal of the normal “posture first” strategy, instead interrupting walking in order to perform the second task (13). On the other hand, patients whose gait disturbance is anxiety-related or psychogenic tend to walk better when they are distracted by a second task.

Gait analysis
Video systems have been introduced for clinical gait analysis; ideally, video recordings should be made both from the front and from the side (9). Recordings enable multiple, observer-independent assessments of gait. Quantitative gait analysis, up to and including the three-dimensional registration of all joint movements, is the most precise method of gait assessment. Quantitative analysis is a useful aid in the differential diagnostic classification of gait disturbances, because the highly standardized measurements and the perfor-mance of the test under various different conditions give it a higher diagnostic value than mere observation. Nevertheless, this comes at the price of labor-intensive analysis. Simplified systems (video systems, pressure-sensitive floor mats) are useful for the intra-individual longitudinal assessment of patients with certain types of disorders (e.g., normal-pressure hydrocephalus before and after the removal of cerebrospinal fluid [CSF], Parkinson’s disease before and after a change of medication schedule).

Functional imaging
Functional magnetic resonance imaging (fMRI) and nuclear medical methods such as 18FDG-PET can be used to demonstrate the supraspinal activity associated with different patterns of gait and the cortical correlates of sensory control (10). These methods can reveal, for example, the human correlates of the cerebellar and brainstem locomotor centers known from animal research, whose function may be impaired in gait disturbances of central origin (Figure 2) (11). They do not yet have any clinical application. fMRI and 18FDG-PET provide complementary information: the former is used to study imagined walking, which can be modified at will, while the latter is used to study actual walking. Findings obtained during actual walking are less dependent on the subject’s ability to cooperate; this is an important consideration for elderly patients with gait disturbances of neurodegenerative origin (20).

The main types of gait disturbance in old age
The neurological diseases that arise mainly in old age and have a gait disturbance as their major clinical manifestation are listed in Table 3 (gif ppt), along with the basic components of the treatment for each. Gait disturbances in old age are often of multifactorial origin. The treatment consists of specific therapy for each of the identified components and may include physiotherapy, medications, behavioral therapy, and, in rare cases, surgery. Although physiotherapy is an important part of treatment for nearly all types of gait disorders, its efficacy has not been demonstrated in controlled studies, even for common disorders (21). Particular varieties of physiotherapy can be applied specifically only when the patient’s deficits have been appropriately diagnostically categorized; sensory exercises, balance and coordination training, and biomechanical training can then be used as indicated. Fall prevention measures for patients at risk of falling include patient education, training, and instruction (e.g., regarding suitable shoes). Patients at very high risk of falling should be given appropriate mechanical aids. Whenever parkinsonism (either idiopathic Parkinson’s disease or an atypical parkinsonian syndrome) is suspected, a therapeutic trial with an L-dopa preparation should be performed. The dose should be slowly increased over a period of two weeks to a maximum of about 1000 mg/day in 3 to 5 divided doses, until the therapeutic effect is adequate or side effects arise. If there is still no effect, or only a questionable effect, at two weeks, then the medication should be discontinued; it is important that this should be done gradually. Three specific diagnoses merit special emphasis in the following sections, because they are clinically important, albeit relatively little known: bilateral vestibulopathy, normal-pressure hydrocephalus, and anxiety-related gait disturbance.

Bilateral vestibulopathy
Bilateral, usually incomplete peripheral vestibular deficits are often overlooked in patients whose presenting manifestations are less than dramatic. The typical symptoms are

• gait unsteadiness that worsens in the dark and on uneven ground,
• unsteadiness of the visual image (oscillopsia) and blurred vision during walking, as if the environment were in motion relative to the patient, and
• impaired spatial orientation.

The diagnosis is confirmed by the demonstration of bilateral dysfunction of the vestibulo-ocular reflex (head-impulse test, caloric irrigation of the external auditory canals [22, e5]). The most common cause is ototoxic medication (aminoglycosides); degenerative disorders are another common cause in old age, often combined with peripheral neuropathy (22). The initial goal of treatment is to counteract the progressive loss of vestibular function, if possible. Thus, it is important to identify treatable and reversible causes (avoidance of ototoxic medications, supplementation of vitamin B12 deficiency, adequate attack prophylaxis in Ménière’s disease). Regular physiotherapy with gait and balance training is important to promote visual and somatosensory compensation for the deficit (e6). About 50% of patients experience some degree of improvement, although clinical studies have not shown to date that physiotherapy leads to any objective improvement of balance (e7).

Normal-pressure hydrocephalus
This disease, which classically presents with the clinical triad of gait disturbance, dementia, and urinary incontinence, is important because it is treatable (23). Neuroimaging studies (CT, MRI) show dilated internal CSF spaces and relatively narrow external CSF spaces. Aqueductal stenosis should be excluded by MRI. The gait is typically small-stepped, shuffling, with little rolling of the balls of the feet on each step; the accompanying arm swing is normal, unlike in hypokinetic parkinsonism. The main clinical differential diagnosis is vascular encephalopathy (Figure 4 gif ppt), which can present very similarly.

The diagnostic assessment is shown in Figure 5 (gif ppt). A single CSF removal test is of low specificity (30% to 60%), but repeated tests over several days are much more specific (60% to 100%) (e8). The reported success rate of ventriculoperitoneal shunting varies considerably from study to study (30% to 100%), and appropriate patient selection is the key. The results tend to be best when the gait disturbance is the patient’s main problem and when other potential causes for it are not simultaneously present (e9). When rational diagnostic assessment yields the diagnosis of normal-pressure hydrocephalus, surgery is advisable because it can lead to improvement both of the gait disturbance and of the cognitive deficits, which would otherwise progress.

Anxiety-related gait disturbance
Many elderly patients with gait disturbances are afraid of falling, and this fear itself can be a major contributor to gait impairment. The prevalence of anxiety-related gait disturbance in elderly patients is said to be as high as 85% when milder forms are included (24). Anxious patients walk more slowly than age-matched controls, yet their gait parameters are in the physiological range when normed for speed (24). The fear of falling is associated with anxiety disorders and depression, and it considerably impairs the quality of life (25). Increasingly avoidant behavior further lowers these patients’ confidence in their own walking ability, with the result that the symptoms worsen, in a downward spiral (13). The gait disturbance does not worsen during dual tasking and improves with minimal assistance. As these patients’ anxiety tends to increase and their mobility tends to decrease over time, it is important to provide timely behavior-therapeutic and pharmacological treatment of their psychiatric comorbidity.

A trial of medication with a selective serotonin reuptake inhibitor to treat anxiety and depression is often useful, although there are no controlled studies with anxiety-related gait disorders as the indication. Behavioral therapy can be provided, with the aim of helping patients regain confidence in their own ability to stand and walk safely by means of education and desensitization (e10). Although a relatively large number of studies of behavioral therapy for this indication have been published, there are still no prospective, long-term studies available.

Conflict of interest statement
The authors declare that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.

Manuscript received on 9 November 2009, revised version accepted on 7 January 2010.

Translated from the original German by Ethan Taub. M.D.


Corresponding author
PD Dr. med. Klaus Jahn
Oberarzt Neurologische Klinik
Klinikum der Universität München – Standort Großhadern
Marchioninistr. 15
81377 München, Germany
[e-mail]


@For e-references please refer to:
www.aerzteblatt-international.de/ref1710
A case report is available at:
www.aerzteblatt-international.de/article10m0306

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