Gait Disorders & Falls

Gait disorders represent one of the most common and consequential geriatric syndromes encountered in Australian primary care and emergency departments. Normal gait is a complex motor task requiring integrated function of the musculoskeletal system, peripheral and central nervous systems, vestibular apparatus, vision, and cognition. Disruption at any level produces characteristic gait patterns that provide valuable diagnostic clues.

In Australia, falls are the leading cause of injury-related hospitalisation and death in people aged ≥65 years. According to the Australian Institute of Health and Welfare (AIHW), approximately 133,000 older Australians were hospitalised due to falls in 2021–22, with over 5,300 deaths attributable to falls in 2021. The direct healthcare cost exceeds $2.3 billion annually. Hip fractures, the most feared consequence, carry a 12-month mortality of 20–30% in Australian populations.

The prevalence of gait abnormalities increases sharply with age: approximately 10% of community-dwelling adults aged 60–69 have gait impairment, rising to 30–40% in those aged ≥80, and >60% in residential aged care facilities. Gait speed — often called the "sixth vital sign" — is a powerful predictor of survival, hospitalisation, and functional decline. A gait speed <0.8 m/s is associated with increased mortality and disability in Australian cohort studies.

A systematic gait assessment is the cornerstone of evaluating any patient presenting with unsteadiness, falls, or mobility complaints. The clinician should observe the patient walking at their normal pace, at a fast pace, and (if safe) on tandem (heel-to-toe) walking. Gait analysis should be integrated with a targeted neurological and musculoskeletal examination.

Structured Gait Observation

Observe the following parameters systematically. Each parameter provides localising and diagnostic information:

Standardised Gait and Balance Tests

Standardised tests provide objective, reproducible measures that facilitate communication between clinicians, track progression, and guide intervention. The following are recommended in Australian practice:

Distinguishing Neurologic from Musculoskeletal Gait

A critical clinical skill is distinguishing gait disorders arising from neurological pathology (requiring investigation, specialist referral, and disease-specific treatment) from those caused by musculoskeletal problems (requiring orthopaedic/physiotherapy management, analgesia, and joint protection). The table below summarises key distinguishing features:

Common Neurologic Gait Patterns

Falls in older adults are rarely due to a single cause. The RACGP's Guidelines for Preventive Activities in General Practice (Red Book) and the Australasian Journal of Ageing consensus statements recommend a comprehensive, multifactorial approach to falls risk assessment and prevention. In Australia, the NHMRC-endorsed best practice is to screen all community-dwelling adults aged ≥65 (≥50 for Aboriginal and Torres Strait Islander people) for falls annually.

Multifactorial Falls Risk Assessment

The following domains must be systematically evaluated in every older person presenting with a fall or identified as at risk:

High-Risk Medications and Falls

Medication-related falls are among the most modifiable risk factors. The following medication classes carry the highest fall risk in Australian older adults:

Evidence-Based Falls Prevention Interventions

Vitamin D Supplementation

Parkinsonian and frontal gait disorders are among the most disabling and therapeutically impactful gait disturbances. They reflect dysfunction of the basal ganglia-thalamo-cortical circuits and frontal lobe motor planning areas, respectively. Early recognition and appropriate referral can substantially improve quality of life and slow functional decline.

Parkinsonian Gait — Clinical Features

The hallmark features of parkinsonian gait result from the combination of bradykinesia, rigidity, and postural instability that characterise basal ganglia dysfunction:

• Festination: Involuntary acceleration of gait with progressively shortening steps — the patient's centre of gravity moves forward faster than their feet can keep up, increasing fall risk
• Freezing of gait (FOG): Sudden, transient inability to initiate or continue stepping — most troublesome on initiation ("start hesitation"), when approaching doorways or obstacles, and during turns. May be "on" phenomenon (wearing-off related) or independent of levodopa cycle
• Reduced arm swing: Often the earliest visible sign; typically asymmetric, preceding the onset of lower limb involvement
• Shuffling gait: Short stride length with reduced foot clearance, increasing trip risk
• En bloc turning: Loss of segmental rotation; the head, trunk, and pelvis turn as a single unit, requiring multiple small steps
• Postural instability: Impaired postural reflexes — a pull test showing retropulsion requiring >2 steps to recover indicates Hoehn & Yahr stage ≥3

Frontal Gait Disorder (Gait Apraxia)

Frontal gait disorder, sometimes called "gait apraxia" or "magnetic gait," results from disruption of the frontal-subcortical circuits that mediate motor planning and execution of locomotion. The patient's legs feel "glued to the floor," and the gait is characterised by:

• Magnetic gait: Feet appear stuck to the floor with difficulty initiating stepping despite normal leg strength
• Wide base: Compensatory widening for balance impairment
• Short shuffling steps: Distinct from parkinsonism — often with preserved arm swing
• Start hesitation: May be overcome by visual cueing (stepping over a line or object) or auditory cueing (counting, marching music)
• Difficulty with dual-tasking: Gait deteriorates markedly when walking and talking simultaneously — a key early sign of frontal-subcortical dysfunction
• Urinary urgency/incontinence: Often accompanies gait disorder in normal pressure hydrocephalus (NPH) — the classic Hakim's triad of gait disturbance, cognitive decline, and urinary incontinence

Key Differentials and Investigation Pathway

Referral Timelines

Driving and Mobility Aids

Driving assessment is a critical responsibility when managing patients with gait disorders. Australian road safety legislation requires clinicians to consider fitness to drive in patients with neurological conditions that may impair driving ability.

Mobility Aids and Assistive Technology

Appropriate mobility aids improve safety, independence, and community participation. The choice must be individualised and regularly reassessed:

Human gait is a complex, largely automatic motor programme that requires the integration of multiple neural systems:

Central Pattern Generators

Locomotion is initiated and modulated by central pattern generators (CPGs) in the spinal cord, which produce the rhythmic alternating pattern of leg movements. These CPGs are under the control of supraspinal centres:

• Mesencephalic locomotor region (MLR): Initiates and modulates gait speed; connected to the basal ganglia and cerebellum
• Basal ganglia: The subthalamic locomotor region and substantia nigra pars reticulata modulate gait initiation and automatic stepping via dopaminergic pathways
• Frontal cortex (supplementary motor area, prefrontal cortex): Voluntary gait control, obstacle avoidance, dual-task gait adaptation, and motor planning
• Cerebellum: Coordination, balance, postural adjustments, and gait rhythm; vermis for truncal control, hemispheres for limb coordination

Pathophysiology of Parkinsonian Gait

Dopamine depletion in the substantia nigra pars compacta (exceeding 60–80% before motor symptoms appear) leads to:

• Reduced basal ganglia output via the globus pallidus internus → decreased thalamo-cortical excitation → bradykinesia and hypokinesia of gait
• Impaired scaling of movement amplitude — the automatic "internal cueing" for step length is lost
• Freezing of gait is thought to result from an inability to appropriately switch between locomotion and postural control, particularly when environmental demands change (doorways, turns)
• Non-dopaminergic systems (cholinergic pedunculopontine nucleus, noradrenergic locus coeruleus) contribute to postural instability and freezing, explaining why these features respond poorly to levodopa

Pathophysiology of Frontal Gait Disorder

Disruption of the frontal-subcortical white matter tracts or basal ganglia-frontal connections impairs the motor planning and execution of gait. This may result from:

• Normal pressure hydrocephalus — dilated ventricles compress periventricular white matter tracts carrying corticospinal and fronto-pontine fibres
• Vascular white matter disease — chronic small vessel ischaemia damages the frontal-subcortical circuits (leukoaraiosis)
• Frontal lobe tumours or trauma — direct disruption of supplementary motor area and prefrontal motor planning regions

Clinical Presentation by Cause

The clinical presentation of gait disorders varies by underlying aetiology. A thorough history should address onset (acute vs. subacute vs. chronic), progression (stepwise vs. gradual vs. fluctuating), associated symptoms, and functional impact.

Diagnostic Criteria — Parkinson's Disease (MDS Clinical Criteria 2015)

The Movement Disorder Society (MDS) criteria for Parkinson's disease require:

1. Parkinsonism: bradykinesia plus rest tremor and/or rigidity
2. At least 2 supportive criteria (clear and dramatic levodopa response, levodopa-induced dyskinesias, rest tremor of a limb, positive olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy)
3. No absolute exclusion criteria (cerebellar abnormalities, supranuclear gaze palsy, frontotemporal dementia within 5 years, parkinetic features restricted to lower limbs for >3 years)
4. No red flags that must be counterbalanced by supportive criteria (rapid gait impairment, early severe dysphonia, early severe dysarthria, etc.)

First-Line Investigations (GP / ED)

Second-Line / Specialist Investigations

Australian MBS Items — Relevant Investigations

Falls Risk Stratification

Stratifying falls risk guides the intensity and setting of intervention:

Hoehn & Yahr Staging (Parkinson's Disease)

Pharmacotherapy — Parkinson's Disease

The following medications are used in the management of parkinsonian gait disorders. All should be initiated by or in consultation with a neurologist or geriatrician with movement disorder expertise.

Freezing of Gait — Non-Pharmacological Strategies

Freezing of gait (FOG) often responds poorly to medication alone. The following cueing strategies are recommended and should be taught by physiotherapists:

• Visual cueing: Step over a line, laser line projected from a device attached to the walking frame or rollator
• Auditory cueing: Rhythmic counting ("1-2-3-STEP"), metronome apps, marching music
• Somatosensory cueing: Weight shift side to side before initiating stepping; rocking motion
• Cognitive strategies: Imagine stepping over an obstacle; consciously lift the foot high
• Environmental modification: Remove clutter, widen doorways, use contrasting colour strips at thresholds

Normal Pressure Hydrocephalus — Treatment

Gait Disorder Due to Orthostatic Hypotension

Monitoring Plan

1. 1. Royal Australian College of General Practitioners. Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. Melbourne: RACGP; 2016 (updated 2023).
2. 2. Australian Institute of Health and Welfare. Falls in Older Australians 2019–20: Hospitalisations and Deaths Among People Aged 65 and Over. AIHW Cat. No. INJ 4. Canberra: AIHW; 2022.
3. 3. National Health and Medical Research Council. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Community Care. Canberra: NHMRC; 2009.
4. 4. Verghese J, LeValley A, Hall CB, Katz MJ, Ambrose AF, Lipton RB. Epidemiology of gait disorders in community-residing older adults. J Am Geriatr Soc. 2006;54(2):255–261.
5. 5. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896–903.
6. 6. Movement Disorder Society. MDS Clinical Diagnostic Criteria for Parkinson's Disease. Mov Disord. 2015;30(12):1591–1601.
7. 7. Austroads. Assessing Fitness to Drive: Medical Standards for Licensing and Clinical Management Guidelines — A Resource for Health Professionals in Australia. Sydney: Austroads; 2022.
8. 8. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the updated AGS/BGS clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148–157.
9. 9. Stroke Foundation (Australia). Clinical Guidelines for Stroke Management. Melbourne: Stroke Foundation; 2022 (updated).
10. 10. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1(1):CD012424.
11. 11. Religa D, Cermakova P, Lundin A, et al. Treatment of normal pressure hydrocephalus — a comprehensive review. J Alzheimers Dis. 2021;84(3):927–942.
12. 12. Australian Institute of Health and Welfare. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra: AIHW; 2023.
13. 13. Barban F, Annicchiarico R, Pantelopoulos S, et al. Harnessing virtual reality and augmented reality to combat falls in older adults. Ageing Res Rev. 2020;63:101143.
14. 14. Menant JC, Weber F, Lo J, et al. Best practice recommendations for the choice of footwear for older adults. J Foot Ankle Res. 2023;16(1):33.
15. 15. Galna B, Rochester L, Burn DJ. The impact of motor cognitive interference on gait in people with Parkinson's disease: influence of task complexity and dual-task type. J Parkinsons Dis. 2015;5(2):267–276.