Review
Falls and gait disorders in geriatric neurology

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Abstract

Gait disturbances are frequent in older patients and lead to immobility, falls, and increased mortality. In gerontoneurologic patients a higher prevalence of risk factors for gait disturbances and falls has to be attributed due to neurodegenerative diseases, dementia, delirium, or psychotropic medication. The potential of neurological expertise to contribute to the evaluation and treatment of falls and gait disorders in geriatric patients is still not fully exploited. Sometimes a fall can be an index event to the diagnosis of the underlying disorder. This review, therefore, focuses on the relationship between falls, gait, and neurological diagnosis. It helps to find the correct diagnosis of the underlying disease as one major step in the management of gait disorders and fall prevention. From a pragmatic point of view falls can be classified according to loss or preservation of consciousness. Gait disturbances should be differentiated into gait disorders with and without cognitive impairment. Although gait impairments are influenced by multifactorial parameters, this differentiation may help to find a diagnosis and also to initiate an appropriate, disease-specific therapy. In addition, every fall patient has to be analyzed individually according to his individual risk factors, which all can potentially be influenced to improve mobility and to reduce falls.

Introduction

Falls and gait disorders are relevant problems in the elderly. While at the age of 60 years still 85% have no gait disorders, the prevalence of gait abnormalities rises up to 82% at the age of 85 and older [1]. In the United States 30% of people over the age of 65 years fall each year and in the group of people older than 80 years this proportion is as high as 50% [2]. 25% of deaths due to falls occur in the 13% of people older than 65 years [3].

The danger of falls in elderly people is due to high susceptibility to injuries caused by prevailing diseases e.g. osteoporosis or reduced protective reflexes. Besides the direct risk of fall-related injuries (e.g. major fractures or head trauma) another important consequence of falls is reduced mobility and loss of self-confidence, which in turn leads, therefore, to a significant reduction of quality of life [4], [5]. Recurrent falls often lead to admission of previously independent older people to long-term care institutions with severity of fall-related injuries being a predictor of admission [2], [6]. Although not every fall is caused by a specific gait disorder, there are quite a few neurological conditions with abnormalities of gait and stance which predispose to falls. Therefore, these two conditions are obviously strongly associated and it is worthwile to discuss these two topics together, especially as a fall might be an index event, which draws the attention to abnormalities of gait, or to other underlying pathological and potentially treatable conditions.

Gait disorders are indicators of negative sequelae or even markers for reduced survival [7], [8] caused not only by fall-related injuries but also by reduced cardiovascular fitness or death from the underlying disease. Besides, gait disturbances in older people are predictors for the development of dementia [9].

In geriatric neurological patients a higher prevalence of gait disturbance and falls must be considered because neurodegenerative diseases, dementia, delirium, or psychotropic medication are common in the elderly. As population ages, this will place an increasing burden on health care providers and society. This warrants a systematic review to discuss the assessment and timely differential diagnosis of gait disorders and falls of geriatric patients in order to prevent further falls and other deleterious consequences.

Most reviews dealing with falls in the elderly [10], [11] focus on interventions which must be multifactorial. However, from a neurological point of view, the significance of gait disorders and falls caused by neurodegenerative diseases is steadily increasing as the population ages. A fall can be an index event to the diagnosis of a hitherto unknown underlying disease and hereby help to initiate a timely therapy. Therefore, this review focuses primarily on falls and gait disorders associated to the dysfunction of central nervous system in elderly patients.

Section snippets

Assessment of falls and gait

In the elderly population most often causes of falls [3], [12] have been attributed to accidental or environmental related factors (31%), gait disorders and weakness (17%), dizziness (13%), drop attack (9%), confusion (5%), postural hypotension (3%), visual disorders (2%), or syncope (0.3%). However, many of the accidental falls may really be attributable to a combination of an “accident” and age or disease-related cofactors. Although not all major factors in fall causation are neurologic in

Falls with loss of consciousness

From a pragmatic point of view, the causes for falls can be divided into patients who fall with a loss of consciousness and patients who fall while consciousness is preserved e.g. because they have a disturbance of gait and balance, or because of external reasons. This discrimination, however, may be difficult to make in cognitively impaired elderly patients without an accurate history and/or witness. In case of a self-limiting loss of consciousness with rapid but complete recovery the broad

Gait disturbances and dementia

A strong relationship between gait and cognition has been demonstrated [45]. The presence of cognitive impairments has a high impact on gait disability and is associated to specific diseases, which are discussed in the following section. Gait involves the integration of attention, planning, memory, and other motor perceptive and cognitive processes [46], [47].

Some authors describe a three-level hierarchical model for gait and balance [11], [48], [49], [50] based on the level of neuronal

Gait disturbances due to other neurodegenerative disorders

Other neurodegenerative diseases represent mainly with extrapyramidal symptoms, which influence gait—not necessarily correlated to cognitive dysfunction. Falls resulting from postural instability lead to considerable morbidity and mortality in patients with Parkinsonism [123], [124]. Patients with Parkinson's disease have a five times higher risk to suffer fall-related injuries (e.g. hip fractures) [125].

Interventions and therapeutical options

Gait, mobility and balance are crucial parameters that affect activities of daily living. A history of falls is a predictor of future falls. A comprehensive neurologic examination is one major tool to assess the risk of fall besides additional screening instruments such as the ‘get up and go’ test, Tinetti mobility index and others.

Neurologists and psychiatrists are often confronted with diseases which increase the risk of falls, e.g. neurodegenerative disorders, dementia, stroke, peripheral

Conclusive remarks

In summary, every fall patient has to be analyzed individually according to his specific disease and his individual spectrum of additional risk factors. Neurological expertise helps to make a diagnosis and consequently leads to disease-specific therapy. Sometimes a fall can be an index event to the diagnosis of the underlying neurological disorder and specific characteristics of gait disturbances – although considerable overlap between neurological disorders exists – can contribute to the

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