Geriatric MedicineTier 1Approach to a presentation

Gait abnormalities or gait disorders

Red flags

Acute onset gait change -> stroke, spinal cord compression, fracture until excluded
Associated urinary/bowel dysfunction + gait change -> cord compression, cauda equina, NPH
Falls with head strike on anticoagulation -> subdural hematoma
Rapidly progressive gait disorder over days-weeks -> consider paraneoplastic, CJD, structural lesion
Focal neurological signs - hemiparesis, foot drop, sensory level

Differential by mechanism

Neurological

Parkinsonian - shuffling, festinating, reduced arm swing, stooped
Ataxic - wide-based, cerebellar or sensory (proprioceptive loss - worse eyes closed/dark)
Spastic/hemiparetic - post-stroke, myelopathy
Frontal gait disorder - wide-based, shuffling, "magnetic" - NPH, vascular dementia, frontal lesions
Peripheral neuropathy - steppage gait (foot drop)

Musculoskeletal

OA hip/knee - antalgic gait
Deconditioning/sarcopenia - generalised weakness
Foot pathology - pain avoidance pattern

Other

Vestibular - unsteadiness, veering, associated vertigo
Visual impairment - cautious, wide-based gait
Cardiovascular - orthostatic hypotension, arrhythmia causing near-syncope during ambulation
Fear of falling (post-fall syndrome) - psychogenic overlay, gait becomes cautious/rigid

Focused history

Onset/tempo - acute vs insidious
Falls history, near-misses, fear of falling
Associated symptoms - pain, weakness, numbness, urinary/bowel symptoms, vertigo, visual change
Medication review - sedatives, antihypertensives, anticholinergics
Functional impact - mobility aids, distance walked, home layout
Past history - stroke, Parkinson's, diabetes (neuropathy), OA, previous fractures

Focused examination

Observe unaided gait - base, stride, arm swing, turning, initiation, freezing
Timed Up and Go (>=12s = increased falls risk), gait speed
Neurological - tone, power, reflexes, plantar responses, sensation (proprioception, vibration), cerebellar signs
Romberg's test - sensory ataxia
Joint exam - OA, deformity, range of movement
Visual acuity, postural BP (lying/standing)
Cognitive screen - frontal gait disorders often accompany cognitive impairment

Investigation strategy

Guided by findings, not routine panel
Bloods if metabolic/neuropathy suspected - B12, TSH, glucose, UEC
Imaging - CT/MRI brain if new focal signs, cognitive-gait syndrome (NPH triad), spine MRI if myelopathy/cord compression signs
Nerve conduction studies if peripheral neuropathy suspected and cause unclear
Postural BP, ECG/Holter if cardiovascular contribution suspected

Management

By mechanism

Parkinsonian - dopaminergic therapy, physio (cueing strategies)
Sensory ataxic - correct reversible cause (B12), balance/strength training, walking aid
Musculoskeletal - analgesia, joint replacement if appropriate, physio
Frontal/NPH - specific workup; VP shunt if NPH confirmed and gait-predominant
Deconditioning - structured strength/balance exercise program (highest-yield intervention across most causes)

General

Falls risk assessment and multifactorial intervention (see falls note)
Home OT assessment, mobility aid prescription and training
Footwear review, vision correction
Medication rationalisation (deprescribing sedatives/antihypertensives contributing to instability)

Traps

Attributing gait change to "old age" without examining for a treatable cause
Missing NPH triad (gait, incontinence, cognitive decline) - reversible with shunt
Fear of falling causing a cautious gait mistaken for a new neurological disorder
Not observing unaided gait - relying on history alone

Talk track

Classify by pattern - parkinsonian, ataxic, spastic, frontal, antalgic, or fear-related - then target investigation to the pattern rather than a blanket panel. Always exclude reversible/urgent causes (cord compression, NPH, B12 deficiency, orthostatic hypotension) before labelling as deconditioning. Structured exercise and deprescribing are usually higher-yield than further imaging.

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