Multifactorial Gait Disorder

Multifactorial gait disorder is gait impairment in older adults caused by the accumulation of several deficits in sensory, neurological, musculoskeletal and cardiovascular function, none of which alone would cause a major gait disturbance.

More than a third of people over 70 have an abnormal gait, and the proportion keeps rising with age. It is a leading cause of falls and loss of independence.

Pathophysiology. Safe walking depends on vision, vestibular function, proprioception, central integration, muscle power, joint mobility and circulatory control. Peripheral neuropathy, visual loss, vestibular decline, osteoarthritis, foot disease, sarcopenia, cerebral small vessel disease, postural hypotension and drug effects each add burden until compensation fails.

Slow, short stepped, wide based or unsteady gait with difficulty turning, reduced arm swing, shuffling, a stooped posture and falls. Features of individual contributors are often present, such as sensory loss in the feet, joint pain or visual impairment.

Observe walking (speed, step length, base, turning, start and stop), and perform timed tests such as the timed up and go. Examine vision, hearing, vestibular function, proprioception, power, tone, reflexes, joints and feet. Measure lying and standing blood pressure and review medicines. Test full blood count, glucose, thyroid function, vitamin B12, renal function and vitamin D. Image the brain or spine when focal signs or cognitive change are present.

Differential diagnosis.

• Higher level gait disorder, normal pressure hydrocephalus and vascular parkinsonism.
• Parkinson disease and cerebellar disease.
• Cervical myelopathy and peripheral neuropathy.
• Cardiac causes and cardiovascular drug effects.

Treat each contributing deficit: correct vision (including cataract surgery), treat neuropathy and B12 deficiency, manage joint pain, provide podiatry and supportive footwear, remove or reduce culprit drugs and treat postural hypotension. Prescribe physiotherapy with gait, balance and strength training, and issue a walking aid with training. Modify the home environment.

Monitoring. Gait speed and falls at each review.