Gait disorders in the elderly.

gaIt and balance both declIne wIth normal, or non-pathological aging. Gait and posture tend to become parkinsonian, meaning “looks like Parkinson’s disease.” This connotes a stooped posture, reduced armswing, reduced stride length and a tendency towards a flat foot strike However, a large number of pathological changes may develop contributing to this normal decline. Some of these involve the nervous systems, central or peripheral, and some involve non-neurological systems which not neurologically controlled. It is obvious that gait difficulties and imbalance contribute to reduced quality of life. It is uncommon to meet a patient in a nursing home who walks normally. Gait impairment and the risk of falls is one major contributing factor to nursing home placement. Falls are common in the elderly. There are different definition for “fall,” but the World Health Organization definition of a fall (E880-E888 in ICD 9 and W00-W19 in ICD 10) requires the person to come to rest “inadvertently” at a lower level than intended. I consider trips and slips as different although possible indicators of a falling tendency. We all may slip on ice, or trip over a plug, but it is an indicator of a problem if it is recurrent, suggesting a problem correcting the loss of balance. Over 30% of community dwelling people over 65 fall at least once each year and falls were the leading cause of traumatic death and morbidity in the elderly. The death rate from falls skyrockets with age, increasing from ten per 100,000 per year for ages 65-74, to 147 per 100,000 per year for those over age 85. The financial costs alone are astronomical and increasing. The claim that “falls among older adults are preventable,” is akin to stating that cigarette smoking or drug addiction or obesity is preventable. The correct statement is, and should be, “falls in the elder can be reduced.” They cannot be prevented, partly due to impaired cognitive function that often accompanies gait disorders in the elderly. My own experience, from talking to patients and from reviewing doctor notes is that many patients do not have their walking evaluated during their routine primary care physician (PCP) appointments. In a study of hospitalized patients, often admitted after a fall, gait was not documented on the chart. The reasons for this are manifold, but I believe that two, which are virtually never discussed, are: doctors have not been taught how to evaluate gait and that most doctors lack a vocabulary for gait, and therefore have difficulty describing what they see. Walking requires the ability to stand, maintain position (keeping center of gravity over the feet) and advance. The overall controlling mechanism is the brain, but, obviously, the feet, ankles, knees and hips must be able to bear the weight; the muscles must be sufficiently strong. The inner ear must be able to determine the direction of gravity’s pull. Binocular vision is important for judging distance and compensating for other impaired sensory systems. The peripheral nerves must convey information from the environment in to the spinal cord, and then out to the appropriate muscles at the appropriate time (“garbage in, garbage out”). And aging affects each of these systems, often in very unequal ways. Determining an exact cause of a gait abnormality is sometimes impossible, although identifying which systems contribute to the process is usually not that difficult to determine.