Assessment of the Geriatric Patient: Gait and Balance

Mark E. Williams, MD; Angela Gentili, MD


November 16, 2009

In This Article

Abnormal Findings: Conditions to Consider

  • Sitting balance and arising from chair
    If the patient has difficulty balancing in the chair or cannot rise without using his or her hands on the arms of the chair, consider proximal muscle weakness, arthritis, or neurologic disease. Treatment options for this area of impairment include raising the height of the seat, muscle-strengthening exercises, and treatment of specific conditions, such as arthritis.

  • Neck turning and extension
    If the patient has limited neck range of motion or experiences symptoms with neck movement, then consider cervical arthritis, cervical spondylosis, or vertebral-basilar insufficiency. Treatment options include avoidance of quick head-turning, turning the body with the head (en bloc), and storing objects low to avoid looking up into high cabinets.

  • Standing balance
    The patient who is unsteady standing may have orthostatic hypotension, cerebellar disease, sensory deficits, muscle weakness, or pain. Treatments or adaptations include changing position slowly (with leg pumps before standing by raising up on the toes to pump the gastrocnemius), muscle strengthening, using an assistive device, improved foot care, medication adjustment, and treatment of specific diseases.

  • Standing with eyes closed (Romberg's test)
    As mentioned earlier, if the patient has a positive Romberg's test, then there is a sensory deficit (eg, vision, peripheral vestibular, or peripheral neuropathy) or decreased position sense (dorsal column problem). The lesion implies spinal cord disease if Babinski's sign is present or neuropathy if the ankle jerks are absent. Treatment options include improving lighting, using night-lights, prescribing assist devices, and changing footwear.

  • Sternal nudge
    This part of the assessment is to gently nudge the patient's sternum to see how he or she responds. Make sure that the patient is well protected before giving the nudge. If the patient staggers and becomes unstable, consider neurologic disease and back disease. Treatment options include removing obstacles, using assist devices, avoiding slipper footwear, and treating specific conditions. These are patients to observe closely during acute illness.

  • Unstable turning around
    If the patient is unstable when turning around, consider cerebellar disease, hemiparesis, visual field cut, or reduced proprioception. Treatment possibilities include assistive devices, proper shoes, gait training, and reducing obstacles.

  • Unsafe sitting down
    The elderly person who crashes down into the chair may have proximal muscle weakness, poor vision, or apraxia. Treatment options include muscle strengthening, raising the height of the seat, and visual assessment.

Here is an example of an exercise to strengthen muscles that I give to patients who watch television in the evening. When a commercial comes on, they are to immediately straighten the right leg and hold it straight with the foot off the floor until the commercial is over. When the first television commercial concludes, the right leg is lowered and the left leg is straightened and held until the second commercial is over. The right leg is raised for the third commercial and so on until the commercial break is over and the program resumes. This sequence should be performed for every commercial break during a 1-hour television program. The goal of this exercise is strengthening of the quadriceps muscles.