Walking funny? You could be ill

A fascinating and yet frustrating aspect of geriatric medicine is the widespread lack of curiosity among healthcare professionals as to the causes of acquired disability in later life.

This is nicely illustrated by the joke about the 95-year-old who goes to the doctor with a sore knee. On being told that it is just his age, his riposte is that the other knee is also 95 years old and doing just fine!

Over future columns I would like to introduce readers to some new thinking on disability in later life, starting with disorders of gait and balance, ie, no longer being able walk in an agile and nimble way.

A key emerging concept is vascular gait dyspraxia, where the fine co-ordination of walking is disrupted by usually silent chronic stroke disease. This is important in public health terms, as control of risk factors for heart disease may reduce the burden of gait disorder into the future.

Many older people suffer from unsteadiness when walking. However, in clinical practice this is often met by a lack of diagnostic curiosity as to what is causing it and frequently therapeutic nihilism.

This is a pity, because a gait disorder is always an indicator of usually undetected illness or illnesses, and therefore presents a double opportunity: to treat the underlying condition and the gait abnormality.

As with many geriatric syndromes, the improvements gained through focused diagnosis and treatment may appear modest, but can make a big difference to one’s function and quality of life.

Walking aid

The safest point of departure is that if an older person cannot walk in a reasonably nimble fashion without an aid, then he or she has a gait disorder, which a positive clinical approach is likely to alleviate.

A challenge is that older people often unconsciously adapt to, and develop, an acceptance of gait and balance disorders, particularly those that develop slowly.

Unlike pain or breathlessness, they may not see problems with walking as a symptom worth bringing to their doctor’s attention, or believe that it is possible to do much about it. Indeed, it is remarkable how they normalise their compensatory strategies, such as “furniture crawling”, a classic response to more severe levels of gait disorder.

Gait disorders often arise from a combination of fairly obvious circumstances, such as arthritis or overt illnesses such as Parkinson’s disease and stroke. Still, it became increasingly clear to geriatricians that in a majority of cases these factors were either absent or not present to a degree to explain the disorder adequately.

A key researcher was Dr Richard Liston, now a geriatrician in Tralee, who proposed that these are higher level gait disorders, now more commonly known as vascular gait dyspraxia.

Vascular gait dyspraxia may present with elements of reduced balance, a failure of initiating walking or both together. If occurring in isolation (ie, no arthritis, no neurological signs other than the gait disorder itself), the diagnosis of vascular gait dyspraxia can be straightforward.

However, if it occurs with other conditions, as is often the case as we age, the diagnosis depends on making a judgment as to whether the degree of gait disorder is consistent with the extent of the other illnesses, or whether it is greater than might be expected, in which case there is vascular gait dyspraxia. If in doubt, an opinion from a geriatrician can be of assistance.

Individually tailored

Management of gait disorders should be individually tailored and multidisciplinary: early intervention can prevent further decline in mobility.

Physiotherapy-based gait and balance re-education programmes lie at the heart of improving mobility status and reduce the risk of falls. Vascular gait dyspraxia can be especially responsive to this therapy, which focuses on improving trunk stability, improving muscle strength and recruiting compensatory strategies.

In addition, a physiotherapist can work on pathologies at other levels, such as muscle strengthening in osteoarthritis and deconditioning.

Continued exercise and physical activity in a community setting can help maintain gait and balance. Home exercise promotes sustained muscle and bone strength, while formal exercise classes can reduce the risk of falls and improve gait and balance.

Vascular gait dyspraxia is generally progressive and decompensation may occur during acute illness (“off legs”). So patients and families should also be advised to reattend their family doctors and community therapists if there is any subsequent deterioration in gait and balance, with a view to reassessment and review of management strategies.

Prof Des O'Neill is a geriatrician at Tallaght Hospital and author of Ageing and Caring: A Guide for Later Life, published by Orpen Press.