Merck Manual

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Gait Disorders in Older Adults


Richard G. Stefanacci

, DO, MGH, MBA, Thomas Jefferson University, Jefferson College of Population Health;

Jayne R. Wilkinson

, MD, MSCE, University of Pennsylvania, Perelman School of Medicine

Reviewed/Revised Nov 2023
Topic Resources

Gait disorders are abnormalities in how people walk, such as losing speed, smoothness, symmetry, or balance.

Walking, standing up from a chair, turning, and leaning are important for being able to move around independently. Gait speed, the time it takes to stand up out of a chair, and the ability to stand with one foot in front of the other (tandem stance) help predict an older person's ability to do daily and other activities such as shopping, traveling, and cooking.

Walking without assistance requires coordination by areas of the brain that control attention, strength, sensation, and coordination of the perceptions of the senses and muscle contraction (see figure ) for safe and steady walking. Dementia and other neurologic disorders can significantly affect walking by impairing these areas of the brain.

Normal Age-Related Changes in Gait

Some elements of gait normally change as people get older; others do not.

Speed of walking (gait velocity) remains the same until about age 70, and then it slows down. Speed of walking is a powerful predictor of mortality—as powerful as the number of chronic medical conditions and hospitalizations a person has. At age 75, slow walkers die 6 years or more before walkers with a normal speed and 10 years or more before fast walkers.

Speed of walking slows because older people take shorter steps. The most likely reason for shortened step length (the distance from one heel strike to the next) is weakness of the calf muscles. Calf muscles propel the body forward, and calf muscle strength declines with age. However, older people seem to compensate for decreased calf strength by using their hip flexor and extensor muscles more than young adults.

Cadence, which is the number of steps taken in a minute, does not slow down with age. Every person has a preferred cadence, which is related to leg length. Tall people take longer steps at a slower cadence; short people take shorter steps at a faster cadence.

Double stancetime refers to the time when both feet are on the ground while taking a step. This phase of a step is a more stable position for moving forward than when only one foot is on the ground. The percentage of time spent in double stance increases with age. Older people may increase the time spent in double stance even more when they walk on uneven or slippery surfaces, when they feel off-balance, or when they are afraid of falling. They may appear as if they are walking on slippery ice.

Walking posture changes only slightly with aging. Older people walk upright, with no forward lean. However, older people walk with more downward rotation of the pelvis and with an increased curve of the lower back (called lumbar lordosis). Usually, weak abdominal muscles, tight hip flexor muscles, and increased abdominal fat contribute to this change in posture. Older people also walk with their legs rotated laterally (toes out) about 5 degrees, possibly because their hips are less able to turn inward or they are trying to increase stability. Foot clearance in swing is unchanged with age.

Abnormal Changes in Gait

A number of disorders can contribute to a dysfunctional or unsafe gait. Common causes are

A gait can be abnormal in various ways, and certain types of abnormalities help doctors understand what is causing the gait problem.

Asymmetry: When healthy, a person’s body moves symmetrically while walking (that is, motions are equal on the right and left sides). If a person consistently does not have symmetry while walking, the cause is often a problem with nerves or bones and joints on one side of the body—for example, a limp caused by a painful hip or ankle. If the reason for the lack of symmetry is not obvious, the cause may be malfunction of the brain or the use of certain drugs.

Loss of synchrony: Normal synchrony of gait involves moving the upper and lower limbs in a regular, rhythmic way and smooth coordination of the limbs. Synchrony enables a person to move forward. Neurologic or musculoskeletal disorders that affect specific aspects of gait result in loss of synchrony.

Difficulty starting or continuing to walk: Older people may have difficulty starting or continuing to walk. When they start to walk, their feet may appear stuck to the floor, typically because they do not shift their weight to one foot to allow the other foot to move forward. Doctors may look for a movement disorder, such as Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more , to find the cause of this gait problem. Once gait is started, a person's steps should be continuous, with little variability in the timing of the steps. Freezing, stopping, or almost stopping usually suggests a cautious gait, a fear of falling, or a problem with the frontal lobe of the brain Cerebrum Cerebrum . Scuffing the feet is not normal (and is a risk factor for tripping). Causes of scuffing include Parkinson disease and weakness and/or numbness of the feet caused by nerve damage Mononeuropathy Mononeuropathy is damage to a single peripheral nerve. Pressure on a nerve for a long time is the most common cause of mononeuropathy. The affected area may tingle, feel prickly, or be numb... read more Mononeuropathy .

Footdrop: Footdrop is difficulty lifting the front part of the foot because of weakness or paralysis of the muscles involved. A person's toe drags when taking a step. To avoid catching the toe, people with a dropped foot may lift their leg higher than normal during a step. Footdrop may be caused by nerve damage or muscle weakness.

Short step length: Short step length may be caused by a fear of falling or by a nerve or muscle problem. The leg with the short step is usually the healthy one, and the short step usually occurs when a person spends less time on the problem leg than on the normal leg during walking.

Increased step width: As gait speed decreases, step width normally increases slightly. A wide-based gait can be caused by a problem in the knees, hips,the brain's cerebellum. Variable step width (lurching to one or both sides) may be due to poor muscle control because of a problem in the brain.

Circumduction: Circumduction is moving the foot in an arc rather than a straight line when stepping forward. Circumduction may caused by pelvic muscle weakness or difficulty bending the knee.

Evaluation of Gait

Doctors try to determine as many potential contributing factors to gait disorders as possible by

  • Discussing the person’s complaints, fears, and goals related to mobility

  • Observing gait with and without an assistive device, such as a cane or walker (if safe)

  • Assessing all components of gait (initiation of gait, right step length and height, left step length and height, and symmetry)

  • Observing gait again with a knowledge of the person’s gait components

Doctors do a physical examination and ask open-ended questions about any difficulty with walking, balance, or both, including whether the person has fallen (or fear they might fall). Doctors also ask about specific capabilities, such as whether the person can go up and down stairs; get in and out of a chair, shower, or tub; and walk as needed to buy and prepare food and do household tasks. Doctors also assess the person's muscle strength, especially in the calves and thighs.

Treatment of Gait Disorders

A gait disorder does not always need to be treated or modified. A slow, abnormal gait may help an older person walk safely and without assistance. However, doctors may offer to treat a person's gait to help improve quality of life. Treatments include exercise Exercise in Older Adults Most people over age 65 do not exercise at recommended levels despite the known health benefits of exercise including Longer survival Improved quality of life (for example, endurance, strength... read more , balance training, and assistive devices.

Strength training

A combination of leg press machines (or alternatively chair rises with weight vests or weights attached to the waist), step ups, stair climbing, and knee extension machines may be recommended to strengthen all the large muscle groups involved in walking.

Nordic walking

Nordic walking is a walking exercise that exercises the whole body. It includes adjustable length walking poles. Compared with traditional walking, the Nordic walking motion uses shoulder and arm muscles and requires greater pelvic rotation, increasing step length and walking speed. When starting a Nordic walking program, frail walkers need supervision and training to use the walking sticks safely.

Balance training

Many people with balance problems improve with balance training. First, health care professionals help teach people a good standing posture and balance while standing still. People are then taught to be aware of the location of pressure on their feet and how the location of pressure moves with slow leaning or turning to look to the left or right. People practice leaning forward (using a wall or counter for support), backward (with a wall directly behind), and to each side. The goal is to be able stand on one leg for 10 seconds.

Balance training can also be more dynamic. Dynamic balance training can involve slow movements in a single stance, simple tai chi Tai chi There are many forms of exercise, and each type has its advantages and disadvantages. Some types of exercise expend more calories than others (see table ). Different forms of exercise (for example... read more movements, tandem (heel to toe) walking, turns while walking, walking backward, walking over a virtual object (for example, a stripe on the floor), slow forward lunges, and slow dance movements.

Assistive devices

Canes are particularly helpful for people with pain caused by knee or hip arthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more Osteoarthritis (OA) or with peripheral neuropathy Overview of the Peripheral Nervous System The peripheral nervous system refers to the parts of the nervous system that are outside the central nervous system, that is, those outside the brain and spinal cord. Thus, the peripheral nervous... read more of the feet because a cane transmits information about the type of surface or floor to the cane-holding hand. A quad cane (one with four small feet at the bottom) can stabilize the patient but usually slows gait. Canes are usually used on the side opposite the painful or weak leg. Many store-bought canes are too long but can be adjusted to the correct height (see figure ).

Walkers can reduce the force and pain at an arthritic joint more than a cane, in people with enough arm and shoulder strength to use them. Walkers provide good stability and moderate protection from forward falls but do little or nothing to help prevent backward falls for people with balance problems. When prescribing a walker, a physical therapist considers the sometimes competing needs of providing stability and maximizing walking efficiency. Four-wheeled walkers with larger wheels and brakes maximize efficiency but provide less stability.

Just the Right Height

Using a cane that is the correct height is important. A cane that is too long or too short can cause low back pain, poor posture, and instability. The cane should be held on the side opposite the weak leg.

Just the Right Height

Prevention of Gait Disorders

Physical activity, done at recommended levels, help older people maintain mobility, even in people with disease.

Regular walking or maintaining a physically active lifestyle is critical to keeping a healthy gait. The adverse effects of being inactive cannot be overstated. A regular walking program of 30 minutes each day is the best single activity for maintaining mobility. However, walking on flat terrain does not increase strength in a person who is weak. Including inclined surfaces, such as hills, during the walk can help maintain leg strength. The use of canes or walking sticks that are adjustable can provide confidence and safety for older adults.

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