Gait disorders are common in older adults, affecting about 35% of people over 70 and 72% of those over 80.
They are a result of neurologic, orthopedic and medical causes (heart failure, lung disease, PAD, obesity).
A gait disorder should be approached as a localization and pattern-recognition problem, not as an inevitable effect of aging; the key first distinctions are acute versus chronic, progressive versus static, painful versus painless, and whether falls or focal neurologic signs are present.
Peripheral neuropathy and radiculopathy are among the most common causes in the elderly.
Main gait patterns
Episodic disturbances should be classified separately from the continuous gait pattern.
Antalgic or mechanical gait: pain, reduced joint range of motion, osteoarthritis, foot deformity, or hip abductor weakness.
Sensory ataxic gait: stamping, impaired vibration or proprioception, distal numbness, and worsening with eye closure; common causes include peripheral neuropathy, vitamin B12 deficiency, and posterior-column disease.
Freezing: brief inability to step.
Festination: involuntary speeding up with small steps.
Sudden loss of balance.
These features point to parkinsonism or lower-body parkinsonism, such as NPH or vascular parkinsonism.
Frontal or “higher-level” gait disorder: initiation failure, freezing, magnetic steps, impaired postural responses, cognitive impairment, and sometimes urinary urgency; consider vascular disease or normal-pressure hydrocephalus.
Parkinsonian gait: reduced stride length, shuffling, reduced arm swing, turning en bloc, bradykinesia, rigidity, or freezing.
A broad base, early recurrent falls, vertical gaze palsy, marked autonomic failure, cerebellar signs, or prominent asymmetry should raise concern for atypical parkinsonism rather than idiopathic Parkinson disease.
Bedside examination
Simple bedside tests,
Eye closure: separates sensory/vestibular ataxia from cerebellar ataxia.
Dual-tasking.
Walking backward.
Tandem gait.
Effect of a walking aid.
External cues (visual, auditory).
Signs that point to a functional disorder:
Scissoring that disappears when walking backward.
Knee buckling that resolves with running or tandem gait.
Grade severity:
Mild: walks without help.
Moderate: needs a walking aid.
Severe: uses a wheelchair or stands only with help.
Mixed disorders are common in the elderly.
Neurologic and non-neurologic causes often exist together, and each contributor should be identified and treated.
Workup is guided by the localization.
Sensory ataxia: B12 level and nerve conduction studies.
Spastic paraparesis: spine MRI.
Frontal gait with cognitive or urinary symptoms: brain imaging to look for NPH or small vessel disease.
Cerebellar or vestibular gait: wide base, veering, dysmetria, nystagmus, or inability to perform tandem gait.
The American Academy of Neurology practice parameter recommends asking about recent falls and examining gait and balance, lower-extremity strength and sensation, coordination, and cognition in patients with conditions associated with increased fall risk.
Most likely diagnostic patterns
Spastic or myelopathic gait: stiff legs, scissoring, hyperreflexia, clonus, Babinski signs, or a sensory level.
Functional gait disorder: diagnosis is supported by positive inconsistencies or incongruencies during examination, but organic disease must still be excluded.
Most important not to miss
Acute stroke or cerebellar hemorrhage: sudden gait or truncal ataxia, focal weakness, dysarthria, diplopia, or new nystagmus.
Spinal cord compression or cervical myelopathy: progressive leg stiffness or weakness, sensory level, hand dysfunction, or new bladder or bowel disturbance.
Medication, orthostatic, or cardiac causes: sedatives, anticholinergics, dopamine blockers, antihypertensives, orthostatic hypotension, arrhythmia, or syncope.
Rapidly progressive ataxia or gait failure: inflammatory, infectious, toxic, nutritional, paraneoplastic, or neurodegenerative disease.
Additional history and examination
The examination is to observe standing from a chair, normal walking, initiation, turning, tandem gait, heel and toe walking, arm swing, base width, step length, freezing, and response to a gentle pull.
A safe Romberg test, eye-movement examination, strength, tone, reflexes, plantar responses, vibration and proprioception, coordination, cognition, orthostatic blood pressure, vision, feet, footwear, medication list, and home hazards help localize the deficit.
A fall history, fear of falling, or abnormal gait screening should prompt targeted assessment of vision, sensation, orthostasis, foot abnormalities, medications, cognition, and the home environment.
Gait speed below approximately (0.8) to (1.0) m/s is commonly used to trigger fall-prevention intervention.
Laboratory tests: complete blood count, electrolytes, renal and hepatic function, glucose or hemoglobin A1c, thyroid-stimulating hormone, and vitamin B12; additional testing should follow the phenotype and tempo.
Imaging: brain magnetic resonance imaging for focal, progressive, atypical parkinsonian, cerebellar, or suspected normal-pressure hydrocephalus presentations; cervical spine imaging for upper motor-neuron signs or a sensory level.
Peripheral evaluation: nerve-conduction studies and electromyography when neuropathy, radiculopathy, or motor-neuron disease is suspected.
Fall reduction: medication review and deprescribing of contributors, physical therapy for strength and balance, an appropriately fitted cane or walker, footwear and vision correction, and occupational therapy/home-hazard assessment.
A structured gait examination with orthostatic vitals, medication review, fall assessment, and focused neurologic localization.
Emergency evaluation is warranted for sudden onset, inability to stand or walk, new focal deficits, severe headache, or new sphincter dysfunction; otherwise, progressive, unexplained, or recurrent-fall gait impairment merits neurologic or geriatric assessment plus physical therapy referral.