Assessment of the Geriatric Patient: Gait and Balance

Mark E. Williams, MD; Angela Gentili, MD

Disclosures

November 16, 2009

In This Article

Examination of the Lower Extremities

The first part of the evaluation of balance and gait is to carefully examine the lower extremities. The initial search is for mechanical problems in the legs. Look carefully for orthopaedic problems, vascular disorders, rheumatic conditions, podiatric concerns (especially shoes), and prostheses. Systematically examine the range of motion of the hips, knees, ankles, and feet. Palpate the femoral, popliteal, dorsalis pedis, and posterior tibial pulses and look for skin lesions.

Check for leg weakness

Once your overall survey is complete, check the muscle strength for any signs of leg weakness. If leg weakness is present, carefully note the distribution. Proximal weakness suggests myopathy, and the patient will have difficulty rising from a sitting position. Distal leg weakness implies neuropathy, and the patient will have difficulty walking on the toes and heels.

If there is a monoparesis, the patient will drag and circumduct the leg. If monoparesis is present, note the deep tendon reflexes. If the reflexes are hyperreflexic, this suggests a central nervous system (CNS) lesion such as an anterior cerebral artery stroke or a parasagittal lesion. Normal or decreased reflexes imply sacral plexus radiculopathy or peripheral nerve problems. Paraparesis (scissors gait) implies a spinal cord, foramen magnum, or parasagittal lesion.

Review the neurologic considerations

Reviewing the presence of neurologic symptoms and signs can help to focus the differential diagnosis

  • Ask about dizziness
    If the patient complains of dizziness or vertigo then consider evaluation for vascular, brain stem, vestibular, or medication problems

  • Check Romberg's sign
    The presence of Romberg's sign implies proprioceptive abnormality. If the spinal cord is involved then the Babinski sign should also be present. If Romberg's sign is due to neuropathy, then the patient's ankle jerks should be absent

  • Look for cerebellar signs
    If the patient has unsteadiness with eyes open, ataxia, or incoordination, then evaluate the rapidity of the onset of symptoms. Sudden onset of gait abnormality implies a posterior fossa stroke. Progressive or subacute onset suggests a mass, demyelinating disease, degenerative disease, drug effect, or metabolic disorder

  • Note any adventitious movements
    If the patient has a resting tremor and difficulty in initiating gait, consider basal ganglion dysfunction and Parkinsonism

  • Check the lower-extremity muscle tone
    If the patient has increased lower-extremity muscle tone (resistance to extension or tonic foot response) and a gait as if feet are stuck to the floor, consider normal-pressure hydrocephalus or frontal lobe dysfunction. If the patient has an unsteady gait with none of the neurologic features listed above, then consider a senile gait or psychiatric illness

  • Perform the Tinetti functional assessment
    The sequence of the evaluation includes sitting balance, neck turning, arising from a chair, standing balance, balancing on one leg then the other, standing balance with eyes closed (Romberg's test), sternal nudge, tandem walk, walking on heels, walking on toes, observing the gait, and sitting down.[1,2] The utility of this assessment is that specific observations of abnormality suggest various treatment options

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