geriatrics
Gait Disorders in Older Adults
Abnormal Changes in Gait
A number of disorders can contribute to dysfunctional or unsafe gait. They particularly include Neurologic disorders Musculoskeletal disorders (eg, Lumbar Spinal Stenosis ) Common neurologic disorders that affect gait include Dementia , There are many manifestations of gait abnormality. Some abnormal gait patterns suggest certain causes. Video demonstrations of selected abnormal gaits are available from theNeuroLogic Exam website. Loss of symmetry of motion and timing between left and right sidesusually indicates a disorder. When healthy, the body moves symmetrically; step length, cadence, torso movement, and ankle, knee, hip, and pelvis motion are equal on the right and left sides. Aregularasymmetry occurs in patients with unilateral neurologic or musculoskeletal disorders (eg, a limp caused by a painful hip or ankle). Loss of synchronycan occur. Normal synchrony of gait depends on regular, rhythmic movement and smooth coordination of upper and lower limbs in a cyclic pattern to move the center of gravity forward. Neurologic or musculoskeletal disorders that affect specific components of gait result in loss of synchrony. Unpredictable or highly variable gait cadence, stride length, or stride width indicates breakdown of motor control of gait due to a cerebellar or frontal lobe syndrome or use of multiple psychoactive medications. may occur. When patients first start walking, their feet may appear stuck to the floor, typically because patients do not shift their weight to one foot to allow the other foot to move forward. This problem may indicate isolated gait initiation failure, Parkinson Disease , or frontal or subcortical disease, including the cognitive abnormalities in is falling backwards when initiating gait or while walking. It may occur in patients with frontal gait disorders, parkinsonism, Syphilis , or Foot dropcauses toe dragging or a steppage gait (ie, exaggerated lift of the leg to avoid catching the toe). It may be secondary to Anterior tibialis weakness (eg, caused by trauma to the peroneal nerve at the lateral aspect of the knee, a peroneal mononeuropathy usually associated with diabetes, or a compression injury) Spasticity of calf muscles (gastrocnemius and soleus) Lowering of the pelvis due to muscle weakness of the proximal muscles on the stance side (particularly the gluteus medius) Low foot swing (eg, due to reduced knee flexion) may resemble foot drop. Short step lengthis nonspecific and may represent a fear of falling or a neurologic or musculoskeletal problem. The side with short step length is usually the healthy side, and the short step is usually due to a problem during the stance phase of the opposite (affected) leg. For example, a patient with a weak or painful left leg spends less time in single stance on the left leg and develops less power to move the body forward, resulting in shorter swing time for the right leg and a shorter right step. The normal right leg has a normal single stance duration, resulting in a normal swing time for the abnormal left leg and a longer step length for the left leg than for the right leg. occurs in patients with Secondary and Atypical Parkinsonism , whether it is due to idiopathic Parkinson disease, Wide-based gait(increased step width) is determined by observing the patient’s gait on a floor with 12-inch (30-cm) tiles. The gait is considered wide based if the outside of the patient’s feet do not stay within the width of the tile. As gait speed decreases, step width increases slightly. Wide-based gait can be caused by cerebellar disease or bilateral knee or hip disease. Variable step width (lurching to one side or the other) suggests poor motor control, which may be due to frontal or subcortical gait disorders. Circumduction(moving the foot in an arc rather than a straight line when stepping forward) occurs in patients with pelvic muscle weakness or difficulty bending the knee. Spasticity of the knee extensor muscles is a common cause. can occur in patients with kyphosis, Parkinson Disease , or disorders with parkinsonian features associated with dementia (particularly is a progressive quickening of steps (usually with forward lean), whereby patients may break into a run to prevent falling forward. Festination occurs most commonly in patients with Parkinson Disease and rarely as an adverse effect of Sideward trunk leanthat is consistent or predictable to the side of the stance leg may be a strategy to reduce joint pain due to hip arthritis or, less commonly, knee arthritis (antalgic gait). In a hemiparetic gait, the trunk may lean to the strong side. In this pattern, the patient leans to lift the pelvis on the opposite side to permit the limb with spasticity (inability to flex the knee) to clear the floor during the swing phase. Irregular and unpredictable trunk instabilitycan be caused by cerebellar, subcortical, or basal ganglia dysfunction. Deviations from pathare strong indicators of motor control deficits. may be reduced or absent in patients with Parkinson Disease or 1.Pau M, Mulas I, Putzu V, et al: Smoothness of gait in healthy and cognitively impaired individuals: a study on Italian elderly using wearable inertial sensor.Sensors20 (12):3577, 2020. doi: 10.3390/s20123577 PMID: 32599872; PMCID: PMC7348719. 2.Muurling M, Rhodius-Meester HFM, Juha Pärkkä J, et al: Gait disturbances are associated with increased cognitive impairment and cerebrospinal fluid au levels in a memory clinic cohort.J Alzheimers76 (3):1061–1070, 2020. doi: 10.3233/JAD-200225 