geriatrics
Gait Disorders in Older Adults
Evaluation of Gait Disorders
The goal is to determine as many potential contributing factors to gait disorders as possible. A performance-oriented mobility assessment tool may be helpful (see table), as may other clinical tests (eg, a screening cognitive examination for patients with gait problems possibly due to frontal lobe syndromes). Identifying which aspects of gait are affected is important. Evaluation is best approached in 4 parts: Discussing the patient’s complaints, fears, and goals related to mobility Observing gait with and without an assistive device (if safe) Assessing all components of gait (see table) Observing gait again with a knowledge of the patient’s gait components In addition to the standard medical history, older patients should be asked about gait-related issues. First, they are asked open-ended questions regarding any difficulty with walking, balance, or both, including whether they have fallen (or fear they might fall). Then specific capabilities are assessed; they include whether patients can go up and down stairs; get in and out of a chair, shower, or tub; and walk as needed to buy and prepare food and do household chores. If they report any difficulties, details of the onset, duration, and progression are sought. History of neurologic and musculoskeletal symptoms and known disorders is important. A thorough Physical Examination is done with emphasis on the Lower-extremity strengthis assessed. Proximal muscle strength is tested by having patients get out of a chair without using their arms. Calf strength is measured by having patients face a wall, put their palms on the wall (to assist balance), and rise onto their toes first using both feet and then using one foot at a time. Strength of hip internal rotation is assessed. Routine gait assessment can be done by a primary care practitioner; a specialist (eg, neurologist) may be needed for complex gait disorders. Assessment requires a straight hallway without distractions or obstructions and a stopwatch. Patients should be prepared for the examination. They should be asked to wear pants or shorts that reveal the knees and be informed that several observations may be needed but that they will be allowed to rest if fatigued. Assistive devices provide stability but also affect gait. Use of walkers often results in a flexed posture and discontinuous gait, particularly if the walker has no wheels. If safe to do so, the clinician should have the patient walk without an assistive device, while remaining close to or walking with the patient with a gait belt for safety. If patients use a cane, the clinician can walk with them on the cane side or take their arm and walk with them. Patients with a suspected peripheral neuropathy should walk touching the clinician’s forearm. If gait improves with this intervention, proprioception from the arm is being used to supplement the missing proprioception from the leg; such patients usually benefit from using a cane, which transmits information about the type of surface or floor to the cane-holding hand. Balanceis assessed by measuring the time patients can stand on both feet in tandem stance (heel to toe) and on one foot (single stance); normal is≥5 seconds. Gait velocityis measured using a stopwatch. Patients are timed while walking a fixed distance (preferably 6 or 8 meters) at their preferred speed. The test may need to be repeated with patients walking as quickly as possible. Normal gait speed in healthy older adults ranges from 1.1 to 1.5 meter/second. Cadenceis measured as steps/minute. Cadence varies with leg length—about 90 steps/minute for tall adults (1.83 meters [6 feet]) to about 125 steps/minute for short adults (1.5 meters [5 feet]). Step lengthcan be determined by measuring the distance covered in 10 steps and dividing that number by 10. Because shorter people take shorter steps and foot size is directly related to height, normal step length is 3 foot lengths, and abnormal step length is<2 foot lengths. A rule of thumb is that if at least 1 foot length is visible between the patient’s steps, step length is normal. Step heightcan be assessed by observing the swing foot; if it touches the floor, particularly in the middle of the swing phase, patients may trip. Some patients with fear of falling or a cautious gait syndrome purposefully slide their feet over the floor surface. This gait pattern may be safe on a smooth surface but is a risky strategy when walking on rugs because patients may trip. Asymmetry or variability of gait rhythmcan be detected when clinicians whisper “dum...dum...dum” to themselves with each of the patient’s steps. Some clinicians have a better ear than an eye for gait rhythm. Testing is sometimes required. CT or MRI of the brain is often done, particularly when gait initiation is poor, cadence is chaotic, or patients appear to have a very stiff gait. Imaging is also helpful if patients have associated signs such as cognitive impairment, abnormal coordination, muscle weakness, or sensory abnormalities. These tests may identify abnormalities such as lacunar infarcts, white matter disease, and focal atrophy and can help determine whether additional testing for normal-pressure hydrocephalus should be considered. Imaging of the lumbosacral spine should be considered if patients have unilateral leg weakness (especially if any sensory deficit is present) or have a spastic gait that suggests a myelopathy that may be secondary to Lumbar Spinal Stenosis . 