Gait disturbances in old age: classification, diagnosis, and treatment from a neurological perspective

Abstract

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.

Figure 1

Changes in walking speed with increasing age. Walking speed with eyes open was measured twice in each of 70 normal subjects: a speed chosen spontaneously by the subject, and the maximum speed of which the subject was capable (Gaitrite walkway system, www.gaitrite.com). Ten persons in each decade were studied (exceptions: 6 persons aged 11–20 and 4 persons aged over 80). The subjects walked a test distance of approximately 14 meters, i.e., one roundtrip to the end of the walkway and back. The temporal and spatial gait parameters were registered for each step. The means and 25th and 75th percentiles are indicated by boxes with a line in the middle, and standard deviations are shown as error bars. (a) The spontaneous speed of gait diminishes slightly with advancing age; (b) the maximum speed diminishes to a more marked extent (data collected by the authors).

Figure 2

The supraspinal control of gait in man. The figure at left shows the areas in the cerebellum and brainstem that are revealed to be active by fMRI during imagined walking; the superimposed designations are those of the locomotor areas that are known from experimental studies in animals (p<0.05 FDR, from [11]. The diagram at right shows the current concept of the supraspinal control of human gait. Impulses from the motor and premotor areas of the frontal cortex disinhibit brainstem locomotor areas by way of the basal ganglia. The signal to initiate or alter the pattern of movement travels from the midbrain via the pontomedullary reticular formation to the spinal generators. The rhythm and speed of gait are modulated by the cerebellum. Afferent signals from the limbs (blue) can modulate the pattern of gait through feedback loops, mainly by way of spinocerebellothalamic connections. CLR, cerebellar locomotor region; CPG, central pattern generator; MLR, midbrain locomotor region; PMRF, pontomedullary reticular formation; SLR, subthalamic locomotor region

Figure 3

The diagnostic approach to the classification of gait disturbances (a) Classification is initially based on the clinical description of the gait disturbances (b) A probable diagnosis is formulated on the basis of the results of ancillary testing and of the patient’s further course (c) The definite diagnosis can only be established by autopsy In this approach, anatomical and etiological classifications are not attempted in stage (a), as these cannot be securely established on clinical grounds alone (e.g., frontal gait disturbance). On the other hand, a correct descriptive designation of the gait disturbance is possible at the beginning, before the ancillary findings and further course are known (e.g., ataxic gait disturbance). Classification modified from Snijders et al. (13)

Figure 4

Typical MRI findings in patients with a “frontal gait disturbance” (axial T2-weighted images): (a) A man with normal-pressure hydrocephalus (ventriculomegaly, narrow sulci) (b) A man with vascular encephalopathy (marked white-matter hyperintensities, normal ventricular size) Patient A could benefit from the insertion of a ventriculoperitoneal shunt, while Patient B could benefit from tight medical treatment of his blood pressure.

Figure 5

A diagnostic algorithm for cases of suspected normal-pressure hydrocephalus. Important differential diagnoses include other central gait disorders, such as vascular gait disturbance in cerebral microangiopathy and hypokinetic parkinsonian syndromes.