Geriatric Gait and Balance Disorders

Disease/ Disorder

Definition

Normal human gait is a complex phenomenon. It is defined as a series of rhythmic, alternating movements of the limbs and trunk that result in forward progression while minimizing the displacement of center of gravity. This is dependent on input from several systems including visual, vestibular, cerebellar, motor and sensory systems.¹ Gait and balance disorders can result from a disruption in any one of these systems and can lead to gait deviations which disproportionately affect the geriatric population.  Gait impairment may precede other impairments (ADL, cognitive impairment) and represent relatively early stage of disablement process. Gait is also increasing recognized as a reflection of overall health of an older individual predicting death and institutionalization. Therefore, gait evaluation should be included in physiatric evaluation of older adults for possible interventions.

Epidemiology including risk factors and primary prevention

It is estimated that the prevalence of gait disorders is only 10% in individuals 60-69 years old but that number increases to more than 60% with age greater than 80 and 82% for those older than 85 years old.² In fact, gait dysfunction is an independent predictor of cognitive decline which may result in increased risk of cardiovascular disease, disability, institutionalization, and death 2.2 times as much compared to older adults without gait disorders.^2,3 Falls are the leading cause of injury for the geriatric population in the United States resulting in 3 million emergency room visits, 800,000 hospitalizations and nearly $50 billion dollars in health care spending each year.⁴ Injuries related to falls can lead to acute injury, short and long-term disability, loss of independence, increased social isolation and death. Nearly 30% of older adults who have had one fall will fall again.⁵

There are many different risk factors associated with gait and balance disorders. Changes in gait in the elderly can often represent an early manifestation of a disease process. Medical conditions that contribute to increased risks include those that manifest symptoms of pain, dyspnea, imbalance, reduced strength, reduced range of motion, changes in posture, impairments in sensory perception, reduced endurance, physical deformity, and impaired awareness of environment.⁶ Most falls are caused by a combination of risk factors; the more risk factors that are present increases the likelihood of falls.

Regular physical exercise has been the most effective form of primary prevention for gait and balance disorders. Exercise should include aerobic exercise, resistance training, stretching exercises, and dynamic standing/balance training.^1,4,7 There are significant risks associated with deconditioning and inactivity and a safe exercise program should be discussed involving patient and family.⁷ Older adults should also receive routine medical care from a medical provider for screenings of common health problems and early management of medical conditions.^1,4

Etiology

Gait dysfunction is described as any deviation of normal walking and gait pattern including deviations in stride length, step length, step width, cadence, stance phase, swing phase, and weight acceptance of single and double limb support.⁸ Specific gait disturbances need to be evaluated through clinical presentation, laboratory work and other diagnostic testing. Common etiologies of these deviations can be broadly categorized into musculoskeletal disorders, central and peripheral neurologic disorders, affective disorders and psychiatric conditions, cardiovascular and pulmonary diseases, infectious and metabolic diseases, sensory abnormalities and transient disorders including any acute illness, hospitalization, surgery or medication side effects. It is important to recognize that many of these conditions can happen simultaneously and increase the overall morbidity and mortality of gait disturbances and balance issues in older adults.^6,10 Prevalent conditions that can lead to gait and balance disorders include^1,6,8-10

• Musculoskeletal disorders
  • Amputation
  • Gout
  • Muscle weakness or atrophy
  • Osteoarthritis
  • Podiatric conditions
  • Spasticity or contractures
• Central Neurologic disorders
  • Cerebellar dysfunction or degeneration
  • Cerebral palsy
  • Cervical spondylosis
  • Cervical spinal stenosis
  • Delirium
  • Dementia
  • Huntington’s disease
  • Lumbar spinal stenosis
  • Microvascular white matter disease
  • Multiple sclerosis
  • Muscular dystrophy
  • Myelopathy
  • Normal-pressure hydrocephalus (NPH)
  • Parkinson disease or other disorder of the basal ganglia
  • Seizures
  • Stroke
  • Traumatic Brain Injury (TBI)
  • Vertebrobasilar insufficiency
  • Vestibular disorders
• Peripheral Neurologic disorders
  • Guillain-Barre Syndrome
  • Peripheral neuropathy
  • Radiculopathy
• Affective disorders and psychiatric conditions
  • Functional movement disorders
  • Depression
  • Fear of falling
  • Sleep disorders
  • Substance abuse
• Cardiovascular and pulmonary diseases
  • Arrhythmias
  • Congestive heart failure (CHF)
  • Coronary artery disease (CAD)
  • Orthostatic hypotension
  • Peripheral arterial disease (PAD)
  • Chronic obstructive pulmonary disease (COPD)
  • Sarcoidosis
• Infectious and metabolic diseases
  • Diabetes mellitus
  • Hepatic encephalopathy
  • Hyponatremia
  • Hypokalemia
  • Hypomagnesemia
  • Human immunodeficiency virus (HIV) associated neuropathy
  • Hyper-and hypothyroidism
  • Obesity
  • Tertiary syphilis
  • Uremia
  • Folate deficiency
  • Vitamin B12 deficiency
  • Vitamin D deficiency
  • Vitamin E deficiency
• Sensory abnormalities
  • Hearing impairment
  • Visual impairment
• Other
  • Acute medical illness of any etiology
  • Recent hospitalization
  • Medication side effects (antiarrhythmics, anticholinergics, anticonvulsants, antidepressants, antihypertensives, digoxin, diuretics, narcotics, psychotropics, and sedative-hypnotics)

Patho-anatomy/physiology

Normal gait occurs in a cycle that starts from the first heel strike, progresses to swinging of one limb while the contralateral limb remains in limb stance.⁹ It follows a sinusoidal pattern involving pelvic rotation in the horizontal plane, pelvic tilt in the frontal plane, lateral displacement of the pelvis, early knee flexion, foot and ankle mechanisms and late knee flexion to maintain center of gravity and balance.^1,9 To achieve this pattern the body relies on central nervous system brainstem, cerebral cortex (motor and premotor), and cerebellum centers as well as somatosensory input, and spatiotemporal coordination to move effectively through space.⁹

In older adults there are several factors attributable to natural aging that can impact the physiology of a normal gait pattern. This includes atrophy of major muscle groups, increased adipose tissue deposition, bone demineralization, decreased brain volumes, frontal gray matter loss, decreased cerebral blood flow, decreased arterial compliance and cardiac output, reduced alveolar surface area with V/Q mismatch, reduced appetite, malnutrition, endocrine disturbances, and reduced glomerular filtration rate.¹

In general, normal age-related gait patterns in the elderly tend to have reduced gait velocity, increased double stance time, walking posture with anterior pelvic rotation and lumbar lordosis, and reduced ankle plantar flexion for pushing off with reduced pelvic motion.¹ Gait speed of 1 m/sec or higher has been reported as a general guide for robust older adults without clinical gait abnormalities.¹⁷

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

As there are many different disease processes that lead to gait and balance disorders, there are also many manifestations of abnormal gait that can aid a medical provider in making a diagnosis and appropriate interventions.

Table 1. Common gait disturbances and characteristics^1,6,8,11,12

Observing a patient’s gait and describing pattern using the above terminology can help providers narrow down potential causes of gait disorders and pursue additional work up as indicated.

Specific secondary or associated conditions and complications

Falls are the most common secondary condition related to gait and balance disorders. Falls can lead to a variety of injuries including fractures of the forearm, hip, and pelvis, head injuries, and spinal cord injuries.^1,10 With or without serious injury falls or near falls can result in significant anxiety and/or depression leading to reduction in activity and social isolation.⁵ Other secondary conditions include worsening pain in muscles and joints that are compensating for abnormal gait and increased energy and oxygen use due to inefficient gait patterns. For additional information please see Fall Prevention in the Elderly.

Essentials of Assessment

History

History should include gathering information from the patient directly as well as family/support persons input regarding possible risk factors or active problems with gait and balance. Some older adults may be hesitant to disclose information regarding difficulty ambulating or falls in the home because they fear losing their independence. There may be many factors at play simultaneously and history gathering should be patient specific and fully address any concerns. One also needs to assess environmental contributors, particularly if discussing falls at home or at a site where the patient commonly walks.

Key questions to ask: ^1,4,6,8,10

• Can you describe any acute or chronic medical problems you are experiencing?
• Are you having any active symptoms or complaints today? Complete full ROS.
• Do you have a history of falls? If so, how often do they occur?
• Have you had any injuries related to falls? Were there any preceding symptoms related to the fall? Were there any environmental factors that contributed to the fall (i.e., throw rugs, poor lighting, slippery surfaces)?
• Do you use any assistive devices? How long have you used them?
• Are there any factors that influence difficulty walking and any associated symptoms (i.e., pain, weakness, dizziness)?
• What medications do you take? Do you take any over the counter medications or herbal supplements?
• Have you had any recent changes to medications?
• Can you describe your home environment including number of stairs entering and inside domicile, presence of handrails, bathroom accessibility and any home hazards including broken or uneven steps, throw rugs, or clutter in the home?
• What does your daily routine look like? Do you engage in any regular exercise?
• Have you recently changed your activity level because of fear of falling?
• Who is your main social support including family, friends and neighbors? How often do you need assistance and what kinds of things do you need help with?
• Do you currently or have you ever smoked tobacco or used smokeless tobacco/vape?
• Do you consume alcohol? If so, how many standard drinks do you consume in a day/week?
• Do you use any other substances recreationally? If so, what do you use and how often do you use it?

Physical examination

A comprehensive examination of geriatric individuals should include evaluation of central and peripheral nervous system, musculoskeletal system, cardiopulmonary system, and auditory, vestibular, and visual impairments.^1,4,6,8

• Cognition including mental status exam, orientation, insight, attention and memory
• Sensory exam with light touch, sharp touch, proprioception, vibration, and two-point discrimination.
• Coordination including sitting balance, rapid alternating movements, Romberg test, and evaluating for dysmetria with finger-to-nose and heel-to-shin testing bilaterally.
• Involuntary movements such as tremors, myoclonus, chorea, athetosis, and dystonia
• Muscle tone and spasticity
• Reflexes including superficial reflexes (i.e., plantar), muscle stretch reflexes (i.e., patellar reflex) and primitive reflexes (i.e., Babinski reflex)
• Muscular atrophy or hypertrophy
• Palpation of joints and major muscle groups
• Joint stability or deformities
• Active and passive range of motion
• Manual muscle testing
• Murmurs, arrhythmias, peripheral pulses, and peripheral edema
• Adventitious lung sounds
• Assessment of visual acuity
• Assessment of impaired hearing

Checking vital signs including heart rate, oxygen saturation, and orthostatic blood pressure. Gait and balance testing should also be performed.

• Direct observation of gait and balance with and without any assistive devices.
• Functional reach test: patient stands with feet shoulder width apart; arm is outstretched 90 degrees at the shoulder. Patient then reaches forward in front of their body without moving their feet. Distance is measured with a ruler. Distances of greater than or equal to 7 inches is considered normal for older adults while distances less than 7 inches indicates a balance disorder.
• Timed up and go test (TUG): timed test using assistive device if applicable. Patient is timed rising from a chair without the use of their arms to push off, walk 3 meters (appx 10 feet), turn, return to the chair, and resume sitting. A time of 10 seconds is considered normal for older adults. Times greater than or equal to 14 seconds is abnormal and times greater than 20 seconds is considered to be a severe gait abnormality.

Footwear should be inspected for wear pattern and deformation of upper material. Wear on the lateral heel is normal pattern however, if it is excessive, foot may be positioned supinated and prone to inversion injuries. Medial plantar wear pattern is abnormal indicating collapsing arch and excessive pronation. Wear pattern under the forefoot often reflects the poor clearance of foot during swing phase (i.e. hemiplegic patient). Deformation or excess wear of the upper over the big toe may be from extensor Babinski response due to central nervous system disorders.

Psychiatric causes of gait and balance disorders are typically a diagnosis of exclusion and comprehensive physical assessment should be performed to identify any inconsistencies between patient reported symptoms and objective physical assessment findings.

Functional assessment

When assessing gait, it is important to perform an assessment in an area without distractions or obstructions. Gait should be assessed both with and without an assistive device with appropriate safety measures including 1 or 2 assistants or gait belt for support. Key aspects of gait that should be assessed include^1,8,13

• Balance: assess how long a patient can stand on both feet while in tandem stance and how long they can maintain balance on 1 foot and then the other. A stopwatch should be used, normal is greater than or equal to 5 seconds.
• Cadence: Using a stopwatch this is measured in steps per minute. Cadence varies based on leg length but healthy range for older adults is approximately 90 steps/minute for individuals around 6 feet tall to 125 steps/minute for those around 5 feet tall.
• Gait Velocity: Observe patient walking a distance of 6-8 meters (appx 20-25 feet) at a comfortable walking pace as well as walking as quickly as possible while maintaining safety. They are timed using a stopwatch. Normal range of gait velocity in older adults typically ranges from 1.1-1.5 m/s.
• Step Length: This varies between patients as step length correlates directly with shoe size and height. This is calculated by measuring the distance walked in 10 steps divided by 10. Normal step length regardless of anthropometric measurements should be 3 foot lengths while an abnormal step length is less than 2 foot lengths
• Step Height: Based on observation of the swing phase of contralateral foot. Step height can be greater than expected in conditions like drop foot or individuals may have shuffling gait where they guide their foot along the floor.
• Asymmetry or variability of gait rhythm: this should be assessed during all phases of the gait assessment. Note whether a patient demonstrates consistent foot falls between phases of gait with both lower extremities (i.e., swing phase and stance phase).

Laboratory studies & imaging

Along with the important role of history gathering and physical assessment, laboratory and imaging studies can yield additional objective data to further narrow possible differential diagnoses. Consider the ordering the following studies as clinically appropriate depending on the differential:^1,6,8

• Laboratory Tests
  • Complete blood count (CBC)
  • Thyroid function test
  • Basic metabolic panel including: electrolytes (sodium, potassium, calcium, chloride), blood urea nitrogen, creatinine, glucose, and carbon dioxide
  • Magnesium
  • Vitamin levels including B1, B6, B12, Vitamin D, and Vitamin E
  • Creatinine kinase (CK)
  • Antinuclear antibodies (ANA)
  • Hemoglobin A1C
  • Rapid plasma reagin (RPR)
  • Urine drug screen
  • Blood alcohol level
  • Liver function tests
  • Lumbar puncture
  • Muscle biopsy
• Imaging Studies
  • Computed tomography (CT) brain
  • Magnetic resonance imaging (MRI) brain
  • CT cervical spine, thoracic spine and lumbar spine
  • MRI cervical spine, thoracic spine and lumbar spine
  • Nerve conduction studies
  • Electromyography
  • Radiograph of hip, knee, and ankles
  • Transthoracic echocardiogram
  • Pulmonary function testing
  • Nocturnal polysomnography
  • Audiometry
  • Visual acuity testing

Environmental

Environmental factors can be a major contributor to falls in individuals both with and without gait and balance disorder. Simple modifications to an older adult’s living environment can help to reduce the risk of adverse events related to a fall. Some specific guidelines include¹⁰

• Remove trip hazards from areas where the individual will be ambulating.
• Keep all floors clutter free and cover electrical cords.
• Add grab bars or raised toilet seat to bathrooms. Grab bars should also be added to showers as well as a shower chair if needed.
• All stairways should have handrails (preferably on both sides.
• Living area and stairways should be well lit at all times.

Social role and social support system

Ability to perform activities of daily living decreases with age even in healthy individuals. It is important to address the concerns of the elderly patient regarding their functional status as well as discuss with support persons in attendance. Support persons may notice changes in gait or early signs of health problems that are unrecognized by the patient. Social support networks can help encourage older adults to follow up with health care providers regarding underlying causes of gait and balance issues as well as encourage safe ambulation with assistive devices, orthotics and modification of the home environment.

Rehabilitation Management and Treatments

Available or current treatment guidelines

As with any medical condition, management and treatment is largely dependent on the causes of an individual’s gait and balance disorder.⁹

Optimized management of medical conditions such as diabetes, CHF, CAD, hypertension, anxiety/depression, substance abuse, liver failure, osteoarthritis and seizure disorders can help to mitigate long term debility and improve functional status.^1,2,6 Close review of patient medications for these conditions can help reduce the number of potentially dangerous medication side effects that increase the risk of falls and injury. Specifically gradual withdrawal of psychotropic medications leads to a reduction in rate of falls.^1,6 In certain cases surgical management may be indicated for those with cervical spondylotic myopathy, lumbar spinal stenosis, NPH, or significant osteoarthritis of the knee and hip.⁶ For patients with visual or auditory impairments appropriate glasses or hearing aids are necessary.

A multi-factorial approach with individual and group balance exercises, gait training exercises, and physical and occupational therapy can help to overcome or improve most gait disturbances once reversible causes have been identified and treated.^1,6,14 Physical therapy evaluation can help to develop a specific exercise and balance activity regimen that can gradually build skills based on a patient’s current functional status. Some specific exercise disciplines that are more advanced combine mind, body, and balance include yoga and Tai Chi. A 2017 meta-analysis of exercise techniques showed that participating in a Tai Chi program of 12-26 weeks reduced the risk of significant falls by 43% in the short term (< 12 months) and 13% in the long term (> 12 months). Yoga had had similar success and has proven to be as effective as Tai Chi in preventing falls in older adults. There are many other exercise and multidisciplinary programs that are being investigated for use in older adults including boxing.^1,6

Assistive devices can help older adults increase the area of support and provide improvement in balance and sensory feedback to compensate for many gait abnormalities. Canes (single point, quad cane, and visual impairment cane), Lofstrand forearm orthosis, walkers (standard, front wheeled, or rollator), and crutches are common assistive devices. Orthoses also help correct gait abnormalities such as the ankle foot orthoses (AFO) which can compensate for foot drop commonly seen in hemiplegic and neuropathic gait patterns. Assistive devices need to be specifically adjusted to fit an individual’s anthropometric measurements and they should receive proper training on how to use the device with direct observation. Family members or support persons should also be trained on how to safely use the devices.^1,4 Occupational therapists may recommend the safest way to perform basic and instrumental activities of daily living and home modifications.

Active and passive range of motion exercises to improve spasticity and increased tone can also help improve gait and balance. Evaluating patients for possible splinting or casting of affected joint can help prevent contractures.¹ Pharmacological treatment of spasticity should be patient specific and determined by underlying causes. Centrally acting oral medications include baclofen, benzodiazepines, clonidine, tizanidine, gabapentin. The only peripherally acting antispasmodic currently used is dantrolene. In specific cases chemical denervation using botulinum toxin phenol and ethanol can also be considered.⁸

Patient & family education

Patient and family education is a crucial element to prevent detrimental effects of gait and balance disorders. Education should be communicated clearly and take into account patient and family preferences such as visual, auditory, written or demonstrative techniques. A multi-factorial approach is often most effective. All education should contain a teach-back component to ensure that patients and their families understand the information discussed.

Some key education topics include

• Home and environmental safety
• Activity limitations such as not driving following a stroke or seizure
• Side effects of current medications
• Proper use of assistive devices
• What to do following a fall
• Anticipatory guidance regarding specific disease conditions

Cutting Edge/ Emerging and Unique Concepts and Practice

There are many new and developing identification tools and treatments for older adults with gait and balance disorders. Some recent tools utilize accelerometer-based body worn monitors (BWM) to assess postural control, balance, and mobility. This can provide more specific information regarding gait patterns that cannot be fully observed in the outpatient setting. There are also smartphone applications that can monitor gait and posture in older adults to provide more accurate data regarding activities of daily living (ADLs) and postural tasks.^4,15

Robotics have also made some significant headway to more accurately assess and treat balance and gait disorders. The two main categories of robotic devices are end-effector devices and exoskeletons. End-effector robots can assist by simulating normal human gait and providing support based on patient needs in both the swing and stance phase of gait. New models allow for more complicated exercise simulations that can represent climbing up and down stairs, walking on rough or uneven surfaces, and can even simulate stumbling events to promote a patient’s ability to recover and prevent falls. Exoskeletons take into account motor control programs which promote patient ability to re-learn motor skills. The exoskeleton provides structural support but allows the patient to control velocity, cadence, and step length to promote re-learning of motor skills in the brain.¹⁶ Virtual reality continues to make advances as well. Visual-vestibular stimulation and postural training showed significant improvements in balance following 6 weeks of Balance Rehabilitation Unit training (BRU).³ Virtual reality using a Wii console with activities such as Wii Fit soccer, snowboarding and Table Tilt improved TUG times and reduced sway length in the treatment group. Games including virtual dance training can also improve balance and gait in older individuals. Virtual reality can also simulate potentially dangerous environments when used in conjunction with treadmill training such as navigating slippery surfaces.³

Gaps in the Evidence-Based Knowledge

Future research in the field of gait and balance disorders should continue identify major barriers faced by older adults in the United States to implementing an active and healthy lifestyle. Evaluation and comparison of cutting-edge interventions in the fields of technology, robotics and virtual reality will be crucial to fund and distribute the most cost-effective interventions to reduce the morbidity and mortality of gait disturbances in older adults.

References

1. Cifu DX. Braddom’s physical medicine and rehabilitation E-book. Elsevier Health Sciences; 2020.
2. Ronthal M. Gait disorders and falls in the elderly. Medical Clinics. 2019;103(2):203-213.
3. Osoba MY, Rao AK, Agrawal SK, Lalwani AK. Balance and gait in the elderly: A contemporary review. Laryngoscope investigative otolaryngology. 2019;4(1):143-153.
4. Khanuja K, Joki J, Bachmann G, Cuccurullo S. Gait and balance in the aging population: Fall prevention using innovation and technology. Maturitas. 2018;110:51-56.
5. Ang GC, Low SL, How CH. Approach to falls among the elderly in the community. Singapore medical journal. 2020;61(3):116.
6. Salzman B. Gait and Balance Disorders in Older Adults. Vol 82.; 2010. In:2020.
7. Organization WH. Global action plan on physical activity 2018-2030: more active people for a healthier world. World Health Organization; 2019.
8. Frontera WR, DeLisa JA, Gans BM, Robinson LR. DeLisa’s physical medicine and rehabilitation: principles and practice. Lippincott Williams & Wilkins; 2019.
9. Ataullah A, De Jesus O. Gait disturbances. In: StatPearls [Internet]. StatPearls Publishing; 2022.
10. Sarmiento K, Lee R. STEADI: CDC’s approach to make older adult fall prevention part of every primary care practice. J Saf Res. 2017;63:105-109.
11. Li S. Ankle and foot spasticity patterns in chronic stroke survivors with abnormal gait. Toxins. 2020;12(10):646.
12. Macchi ZA, Kletenik I, Olvera C, Holden SK. Psychiatric comorbidities in functional movement disorders: a retrospective cohort study. Movement disorders clinical practice. 2021;8(5):725-732.
13. James OJ, MD. Gait Disorders in Older Adults. Mereck Manual Professional Version September 2022.
14. Moreland B, Kakara R, Henry A. Trends in nonfatal falls and fall-related injuries among adults aged≥ 65 years—United States, 2012–2018. Morb Mortal Weekly Rep. 2020;69(27):875.
15. OLDROYD AG. Utilising Smartphone-Based Apps and Wearable Accelerometer Sensors in Idiopathic Inflammatory Myopathies to Improve Treatment and Research. 2021.
16. Iandolo R, Marini F, Semprini M, et al. Perspectives and challenges in robotic neurorehabilitation. Applied Sciences. 2019;9(15):3183.
17. Oh-Park M, Holtzer R, Xue X, Verghese J. Conventional and robust quantitative gait norms in community-dwelling older adults. J. Am. Geriatr. Soc. 2010;58(8):1512-1518.

Original Version of the Topic

George Forrest, MD, Zachary Schott, MD, Gabriel Radu, DO. Geriatric gait and balance disorders. 9/20/2013

Previous Revision(s) of the Topic

Mooyeon Oh-Park, MD and Tomas Salazar, MD. Geriatric gait and balance disorders. 8/17/2017

Author Disclosure

Sunil K Jain, MD
Nothing to Disclose

Kathryn Chrisfield, MSN
Nothing to Disclose