Elsevier

The Lancet Neurology

Volume 6, Issue 1, January 2007, Pages 63-74
The Lancet Neurology

Review
Neurological gait disorders in elderly people: clinical approach and classification

https://doi.org/10.1016/S1474-4422(06)70678-0Get rights and content

Summary

Gait disorders are common and often devastating companions of ageing, leading to reductions in quality of life and increased mortality. Here, we present a clinically oriented approach to neurological gait disorders in the elderly population. We also draw attention to several exciting scientific developments in this specialty. Our first focus is on the complex and typically multifactorial pathophysiology underlying geriatric gait disorders. An important new insight is the recognition of gait as a complex higher order form of motor behaviour, with prominent and varied effects of mental processes. Another relevant message is that gait disorders are not an unpreventable consequence of ageing, but implicate the presence of underlying diseases that warrant specific diagnostic tests. We next discuss the core clinical features of common geriatric gait disorders and review some bedside tests to assess gait and balance. We conclude by proposing a practical three-step approach to categorise gait disorders and we present a simplified classification system based on clinical signs and symptoms.

Introduction

Gait disorders are common in elderly populations and their prevalence increases with age. At the age of 60 years, 85% of people have a normal gait, but at the age of 85 years or older this proportion has dropped to 18%.1, 2 Gait disorders have devastating consequences. Perhaps the most notorious corollary is falling, which is often caused by an underlying gait problem. Injuries caused by accidental falls range from relatively innocent bruises to major fractures or head trauma. Another important consequence is reduced mobility, which leads to loss of independence. This immobility is often compounded by a fear of falling, which further immobilises patients and affects their quality of life.3 Importantly, gait disturbances are also a marker for future development of cardiovascular disease and dementia.4, 5, 6 These associations suggest that gait disturbances—even when they present in isolation—can reflect an early, preclinical, underlying cerebrovascular or neurodegenerative disease. Finally, gait disorders are associated with reduced survival, which can be attributed to a combination of fatal falls, reduced cardiovascular fitness, and death from underlying disease.7, 8, 9

Elderly patients regularly present with complex gait disorders, with concurrent contributions from multiple causal factors.10 To describe specific gait disorders accurately is often difficult. Here, we provide a practical approach that may support clinicians in their everyday management of neurological gait disorders in elderly people. We briefly address the pathophysiology of gait disorders and discuss the effects of mental function and normal ageing on gait. We conclude by describing a practical clinical approach and simplified classification system to differentiate gait disorders in everyday practice, based on clinically discernable gait patterns. Treatments for geriatric gait disorders are not reviewed.

Section snippets

Pathophysiology of gait disorders

Normal gait requires a delicate balance between various interacting neuronal systems (figure 1) and consists of three primary components: locomotion, including initiation and maintenance of rhythmic stepping; balance; and ability to adapt to the environment. Dysfunction in any of these systems can disturb gait. Most ambulatory problems in elderly people are caused by concurrent dysfunction of multiple systems.

Virtually all levels of the nervous system are needed for normal gait.11, 12, 13, 14

Gait and mental function

Walking is traditionally seen as an automatic motor task that requires little, if any, higher mental functions. In the past decade, new insights have drawn attention to the importance of cognition in daily walking.18 Normal walking requires strategic planning of the best route, as well as continuous interaction with the environment and with internal factors. Failing to understand the significance of an obstacle, choosing an inappropriate route, or misinterpreting one's own physical abilities

Effect of normal ageing on locomotion and gait

Ageing is typically equated with abnormalities, and this association certainly applies to gait. Many older people accept their gait difficulty as being normal for their age and their doctors often support them in this view. But are gait disorders truly an inevitable consequence of ageing itself? This question is illustrated by the evolving concepts around the so-called senile gait disorder: the slow, shuffling, and cautious walking pattern commonly seen in older age. Because clinical

Differentiation of gait disorders

Only few studies describe the distribution of geriatric gait disorders. Obviously, the spectrum of underlying illnesses will depend on the population under consideration and the assessment technique. Within a relatively healthy subgroup of 153 community residents aged 88 years and older, about 61% reported distinct diseases as a cause of gait impairment.1 Non-neurological disorders were the leading causes of gait impairment, in particular joint pain (52 of 87 people), whereas many others had

Recognition of specific gait disorders

Table 1 summarises the main features of the weak, spastic, and ataxic gait disorders (for reviews, see 13, 15, 45, 46). Because these categories usually cause little difficulty in clinical practice, we focus next on the remaining gait disorders.

Assessment of gait disorders

Assessment includes a full physical and neurological examination and a systematic gait assessment. Use of standard rating scales, such as the Tinetti mobility index79 or gait and balance scale,80 help to score all different elements of gait and balance. Most examination rooms are too small, so it is often necessary to examine the patients while walking in the corridor. Simple undisturbed gait can be informative, but additional abnormalities come to light when gait is challenged. For example,

Clinical approach and classification of gait disorders

We conclude our contribution by discussing a new, practically oriented approach to gait disorders, as well as a simplified modification of the classification originally proposed by Nutt and colleagues.98 A broadly accepted classification system would assist health professionals when they communicate about patients with gait disorders. Research will also benefit from a good classification system, for example to ascertain that properly diagnosed patients and homogeneous groups are included in

Conclusions

This review shows that the field of gait disorders is very much on the move, with exciting new insights in the underlying pathophysiology. There is an increasing awareness that gait disorders in old people are often not due to merely ageing, but rather are associated with diseases that are more common in elderly people and which are potentially amenable to therapeutic intervention. Clinical assessment of geriatric gait disorders may seem difficult, but is facilitated by the practical approach

Search strategy and selection criteria

References for this review were identified by searches of PubMed up to August 2006. Papers were also identified from the authors' own files and from references given in relevant articles. Search terms “gait”, “gait disorder”, “locomotion”, “elderly”, “geriatric”, and “ageing” were used.

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