1. GAIT IMPAIRMENT Suggestions for Lecturer -1-hour lecture
-Use GRS slides alone or to supplement your own teaching materials.
-Refer to GRS and Geriatrics at Your Fingertips for further content.
-For strength of evidence (SOE) levels, see the GRS Teaching Slides site or the GRS inside front cover.
-See GRS9 question #s 17, 19, 98, 141, 160, 167, and 196 for additional case vignettes on gait disturbances.

2. OBJECTIVES
Know and understand:
How to perform a diagnostic evaluation of gait dysfunction
How to conduct a gait assessment of the older adult
Understand interventions that can possibly reduce impairment

3. TOPICS COVERED Epidemiology
Conditions That Contribute to Gait Impairment
Gait Assessment
Interventions to Reduce Gait Disorders

4. Gait disorders are common and a predictor of functional decline
EPIDEMIOLOGY
Gait disorders are common and a predictor of functional decline
Certain gait-related mobility disorders progress with age and are associated with morbidity and mortality
Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death
At least 20% of noninstitutionalized older adults admit to difficulty with walking or require the assistance of another person or special equipment to walk. In some samples of noninstitutionalized older adults ≥85 years old, the prevalence of walking limitations can be over 50%. Age-related gait changes such as slowed speed are most apparent after age 75 or 80, but most gait disorders appear in connection with underlying diseases, particularly as disease severity increases. For example, advanced age (>85 years old); three or more chronic conditions at baseline; and the occurrence of stroke, hip fracture, or cancer predict catastrophic loss of walking ability.

5. GLOSSARY OF GAIT ABNORMALITIES (1 of 2)
Term
Description
Antalgic gait
Pain-induced limp with shortened stance phase of gait on painful side
Circumduction
Outward swing of leg in semicircle from the hip
Equinovarus
Excessive plantar flexion and inversion of the ankle
Festination
Acceleration of gait
Foot drop
Loss of ankle dorsiflexion secondary to weakness of ankle dorsiflexors
Foot slap
Early, frequent audible foot-floor contact with steppage gait compensation
Freezing of gait
Sudden, short duration diminution or cessation of walking usually associated with shift in attention or movement circumstance or direction
Topic
Slide 5

6. GLOSSARY OF GAIT ABNORMALITIES (2 of 2)
Term
Description
Genu recurvatum
Hyperextension of knee
Propulsion
Tendency to fall forward
Retropulsion
Tendency to fall backward
Scissoring
Hip adduction such that the knees cross in front of each other with each step
Steppage gait
Exaggerated hip flexion, knee extension, and foot lifting, usually accompanied by foot drop
Trendelenburg gait
Shift of the trunk over the affected hip, which drops because of hip abductor weakness
Turn en bloc
Moving the whole body while turning
Topic
Slide 6

7. CONDITIONS CONTRIBUTING TO GAIT DISORDERS IN PRIMARY CARE
Usually multifactorial:
Degenerative joint disease
Acquired musculoskeletal deformities
Intermittent claudication
Orthopedic surgery
Stroke
Postural hypotension
Dementia
Fear of falling
Visual loss
Although older adults can maintain a relatively normal gait pattern well into their 80s, some slowing occurs, and decreased stride length thus becomes a common feature in descriptions of gait disorders of older adults. Some authors have proposed the emergence of an age-related gait disorder without accompanying clinical abnormalities, ie, essential “senile” gait disorder. This gait pattern is described as broad-based with small steps, diminished arm swing, stooped posture, decreased flexion of the hips and knees, uncertainty and stiffness in turning, occasional difficulty initiating steps, and a tendency toward falling. These and other nonspecific findings (eg, the inability to perform tandem gait) are similar to gait patterns found in a number of other diseases, and yet the clinical abnormalities are insufficient to make a specific diagnosis. This “disorder” may be a precursor to an as-yet-undiagnosed disease (eg, related to subtle extrapyramidal symptoms) and is likely to be a manifestation of concurrent, progressive cognitive impairment (eg, Alzheimer disease or vascular dementia). Thus, “senile” gait disorder may reflect a number of potential diseases and is generally not useful in labeling gait disorders in older adults.

8. CLASSIFICATION OF GAIT DISORDERS
May classify by abnormal sensorimotor level:
Low: peripheral sensory dysfunction
Low: peripheral motor dysfunction
Middle: postural and locomotor impairment
High: cognitive and white matter disorders
These levels may overlap when certain disorders involve multiple levels, eg, Parkinson disease involving high (cortical) and middle (subcortical) structures

9. PERIPHERAL SENSORY DYSFUNCTION
Condition or disease
Clinical/physical findings
Gait abnormalities
Peripheral neuropathy, proprioceptive deficits
Loss of touch sense, loss of position sense
Possible steppage gait; wide-based, unsteady, uncoordinated, especially without visual input; may lift feet high and slap on ground to increase sensory feedback
Vestibular disorders
Dysequilibrium, abnormal Romberg
Weaving (“drunken”), falling to one side
Visual impairment
Visual loss
Tentative, uncertain, uncoordinated
See GRS9 Table 32.2

10. PERIPHERAL MOTOR DYSFUNCTION
Condition or disease
Clinical/physical findings
Gait abnormalities
Painful or deforming conditions
Pain and decreased motion of hip, knee, or spine; signs of arthritis; thoracic kyphosis; decreased lumbar lordosis; stooped posture
Antalgic gait with shortened stance phase on affected side; Trendelenburg gait; buckling of painful limb with weight bearing
Focal myopathic, neuropathic weakness
Proximal muscle weakness, distal muscle weakness, exaggerated lumbar lordosis (secondary to pelvic girdle weakness)
Trendelenburg gait, waddling gait, steppage gait with foot drop or foot slap

11. POSTURAL AND LOCOMOTOR IMPAIRMENT
Condition or disease
Clinical/physical findings
Gait abnormalities
Cerebellar ataxia
Poor trunk control, incoordination or other cerebellar signs
Wide-based with increased trunk sway, irregular stepping, staggering, especially on turns
Parkinsonism
Rigidity, bradykinesia, tremor, stooped posture
Small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en bloc, absent arm swing, freezing of gait
Hemiplegia or hemiparesis
Arm and leg weakness, spasticity, equinovarus, genu recurvatum
Leg circumduction, loss of arm swing, foot drag or scrape
Paraplegia or paraparesis
Leg weakness, spasticity
Bilateral leg circumduction, scraping feet, possibly also scissoring

12. COGNITIVE AND WHITE MATTER DISORDERS
Condition or disease
Clinical/physical findings
Gait abnormalities
Frontal lobe disease, dementia, normal-pressure hydrocephalus
Cognitive impairment, weakness and spasticity, urinary incontinence
Range of findings may include difficulty initiating gait, freezing, leg apraxia, and shuffling gait similar to that seen in Parkinson disease but with wider base, upright posture, preservation of arm swing
Dementia (Alzheimer disease, vascular)
Mid- to late-stage dementia, may have fear of falling
Cautious gait with normal to widened base, shortened stride, decreased velocity, en bloc turns

13. GAIT ASSESSMENT: KEY POINTS
Careful medical history and physical exam can elucidate contributing factors
Laboratory and diagnostic imaging may be warranted, depending on history and physical exam
Use a gait assessment tool (eg, timed Get Up and Go)
Establish person’s comfortable gait speed; use as both assessment and outcome measure
Remember that most gait disorders are associated with underlying disease

14. HISTORY & PHYSICAL EXAM (1 of 3)
Evaluate for evidence of subacute metabolic disease, acute cardiopulmonary disorders, other acute illness
Attempt to identify motion-related factors, eg, by provoking both vestibular and orthostatic responses
Dix-Hallpike test for vestibular dysfunction
Supine and standing BP to exclude orthostatic hypotension
Vision screening, at least for acuity, is essential

15. HISTORY & PHYSICAL EXAM (2 of 3)
Evaluate neck, spine, extremities, and feet for pain, deformities, and limited range of motion, particularly regarding subtle hip or knee contractures
Measure leg-length discrepancies, such as can occur with a hip prosthesis and either as an antecedent or subsequent to lower back pain
Simply measure the distance from the anterior superior iliac spine to the medial malleolus

16. HISTORY & PHYSICAL EXAM (3 of 3)
A formal neurologic assessment is critical; assess strength and tone, sensation (including proprioception), coordination (including cerebellar function), station, and gait
The Romberg test screens for simple postural control and whether the proprioceptive and vestibular systems are functional
Given the importance of cognition as a risk factor, assessing cognitive function is also indicated

17. LABORATORY & IMAGING ASSESSMENTS
A CBC, serum chemistries, and other metabolic studies may be useful when systemic disease is suspected
Head or spine imaging, including radiography, CT, or MRI, are not indicated unless history and physical examination identifies neurologic abnormalities, either preceding or of recent onset, related to the gait disorder
Cerebral white matter changes, often considered to be vascular (termed leukoaraiosis), have been increasingly associated with nonspecific gait disorders (SOE=B). Periventricular high signal measurements on MRI as well as increased ventricular volume, even in apparently healthy older adults, are associated with gait slowing. White-matter hyperintensities, white matter atrophy, and ventricular enlargements on structural MRI correlate with longitudinal changes in balance and gait, and the periventricular frontal and occipitoparietal regions appear to be most affected. Functional MRI generally supports these structural MRI findings, and diffusion tensor imaging techniques show that small vessel disease, even in normal-appearing white matter, can affect gait. Age-specific guidelines for and the sensitivity, specificity, and cost-effectiveness of these evaluations remain to be determined.

18. PERFORMANCE-BASED FUNCTIONAL ASSESSMENT
Comfortable gait speed and related endurance measures (such as 6-minute walk) are powerful predictors of falls, disability, hospitalization, institutionalization, and mortality
Usual gait speed is tested from a standing start over a distance of 4 m
Speed of 0.6 m/s has been proposed as cut point for dysmobility
Speeds of > m/s are associated with better functional outcomes and increased life expectancy
Another endurance measure, the 400-meter walk, has been increasingly used in research settings and considered a marker of major mobility disability that was responsive to a physical activity intervention. Gait speed is faster in individuals who are taller, who have a lower disease burden, and who are more active and less functionally disabled.
Several studies have found age- and disease-associated deficits in the ability to walk and perform a simultaneous cognitive task (“dual tasking,” such as talking while walking), and also linked these deficits with increased fall risk, and include gait speed changes as well as gait variability. However, dual task changes in gait speed as well as variability may be equivalent to single task changes in discriminating fallers from non-fallers even when considering those who walk more slowly or who are cognitively impaired. The dual task effect may thus be most clinically useful in very high-risk groups who require extensive attentional resources to maintain safe gait. Although slower gait speed can predict decreased cognition in healthy older adults, the opposite is true as well, namely that decreased cognitive function, in multiple domains including executive function, is associated with slower speed.

19. THE TIMED UP AND GO TEST (TUG)
Record the time it takes a person to:
Rise from a chair, walk 3 meters, turn, return to sit in the chair
On study suggests a TUG score of ≥ 14 seconds as an indicator of fall risk
Others have found limitations in TUG in the presence of cognitive impairment and difficulty in completing the test due to immobility, safety concerns, or refusal
A number of timed and semiquantitative balance and gait scales have been proposed as a means to detect and quantify abnormalities and to direct interventions. Fall risk, for example, can be increased with more abnormal gait and balance scale scores, such as with the Berg Balance Scale or the Performance-Oriented Mobility Assessment. Another functional approach that can be useful clinically is the Functional Ambulation Classification scale, which rates the use of assistive devices, the degree of human assistance (either manual or verbal), the distance the person can walk, and the types of surfaces the person can negotiate.

20. INTERVENTIONS TO REDUCE GAIT DISORDERS
Many conditions causing a gait disorder are, at best, only partially treatable
Other outcomes, such as pain reduction, may be equally important in justifying treatment
Comorbidity, disease severity, and overall health status tend to strongly influence outcome
Functional improvement becomes the treatment goal

21. EXERCISE AND PHYSICAL THERAPY
Knee osteoarthritis: strength, flexibility, and aerobic exercise, particularly with a single goal and when provided at least 3 times per week, show at least moderate effects in improving overall function
Post-stroke: treadmill training may improve gait speed and walking endurance; electromechanical and robotic assistance may increase likelihood of walking
Parkinson’s disease: PT including complementary treatments yields short-term gains in functional mobility and gait speed
Gait disorders presumably secondary to B12 or folate deficiency, thyroid disease, knee osteoarthritis, and Parkinson disease improve with medical therapy.

22. SURGERY
Lumbar stenosis: Many have reduced pain after laminectomies and lumbar fusion surgery. However, nonoperative treatment can also result in modest improvements such as walking tolerance.
NPH: short-term gait improvement after shunt placement in 60-90%, but long-term maintenance of the improvement can drop to as low as 33%
Hip/knee replacement for OA: pain relief, sizable gains in gait speed and joint motion occur, although residual walking disability continues
Multidisciplinary rehabilitation after or “prehabilitation” prior to joint replacement may have positive effects
NPH = normal pressure hydrocephalus
OA = osteoarthritis

23. MOBILITY AIDS
Lifts (internal or external) to correct limb length inequality, used in a conservative, gradually progressive manner
Ankle braces, shoe inserts, shoe body and sole modifications
Walking shoes with low heels, relatively thin firm soles, and if feasible, high, fixed heel collar support
Canes and walkers reduce load on a painful joint and increase stability
Light touch on a wall, or “furniture surfing,” provides feedback and enhances balance

24. SUMMARY
Gait disorders are common in older adults and are a predictor of functional decline
The cause of gait impairment in older adults is usually multifactorial; therefore, a full assessment must include consideration of a number of different causes, as determined from a detailed physical examination and a functional performance evaluation.
Various interventions, ranging from medical to surgical to exercise, can reduce the degree of impairment, although some residual impairment is often present.

25. CASE (1 of 4)
A 79-year-old woman has fallen twice in her room during the last 2 weeks.
Both falls occurred when she stood up and felt dizzy and lightheaded.

26. CASE (2 of 4)
Examination
Blood pressure is 118/79 mmHg when she is supine and 109/76 mmHg after she stands for 3 minutes.
Cognition is intact.
Patient maintains static body and head position in an upright posture during:
Eyes open, quiet standing on both hard level and soft foam surfaces
Eyes closed, quiet standing on a hard level surface
Patient loses balance and falls to the right during quiet standing on a foam mat with eyes closed.
When she walks, she looks drunk and falls to the right side.

27. CASE (3 of 4)
Which one of the following is the most likely cause of the patient’s falls?
Orthostatic hypotension
Somatosensory deficit
Vestibular deficit
Visual deficit
Peripheral neuropathy

28. CASE (4 of 4)
Which one of the following is the most likely cause of the patient’s falls?
Orthostatic hypotension
Somatosensory deficit
Vestibular deficit
Visual deficit
Peripheral neuropathy
ANSWER: C
Under normal conditions, somatosensory, visual, and vestibular systems play critical roles in maintaining an upright posture; a deficit or misinterpretation of sensory input from one or more of these systems may cause a fall. A person who cannot control his or her standing posture and feels dizzy or lightheaded may have a deficit at the middle sensorimotor level. The Clinical Test for Sensory Interaction on Balance (CTSIB) can be used to differentiate which system is causing the unsteadiness. In the test, one system is blocked or minimized to assess how the other two systems compensate to maintain the body in proper posture.
The assessment as applied here asks the patient to close her eyes in order to block the visual system (which she does without difficulty when she stands on a hard surface, thereby excluding the visual system as the cause of her falls). She also stands on a foam mat without difficulty when her eyes are open, thereby excluding the somatosensory system as the cause of her falls. When the somatosensory system is abnormal, further evaluation should include examination of the peripheral nerves. However, when her somatosensory system is minimized (by standing on a foam mat) while her visual system is blocked (closed eyes), the loss of balance during static standing confirms that the vestibular system does not function well. The Dix-Hallpike test would further document a vestibular deficit.
Orthostatic hypotension (a drop of ≥20 mmHg in systolic blood pressure) is a common cause of falls in older adults. The change in this patient’s systolic pressure (9 mmHg) does not meet the criterion for orthostatic hypotension. When used as part of a multifactorial fall intervention program, measures that reduce medications and optimize fluids, as well as behavioral interventions that minimize orthostatic hypotension, result in a modest reduction in falls (SOE=B).

29. Copyright © 2016 American Geriatrics Society
GRS9 Slides Editor: Tia Kostas, MD
GRS9 Chapter Author: Neil B. Alexander, MD
GRS9 Question Writer: Hao Liu, PT, PhD, MD
Managing Editor: Andrea N. Sherman, MS
Copyright © American Geriatrics Society