Senile Gait

Atraumatic Joint and Limb Pain in the Elderly

Patients who visit the emergency department often have complaints of joint and limb pain. The differential diagnosis, clinical presentation, and treatment choices can be vastly different in the young- or middle-aged population compared with the elderly population, and the concerns of each group must be addressed. The emergency physician is in a unique position in that they are frequently the first to see these individuals and have the opportunity to intervene before permanent disability ensues. Some of the more common etiologies of atraumatic joint and limb pain, including crystal deposition diseases such as gout and pseudogout, osteoarthritis, septic arthritis, and inflammatory arthritides such as rheumatoid arthritis will be addressed in this article. In addition,several arthritides specific to the elderly population such as poly-myalgia rheumatica and associated giant cell arteritis will be covered. Finally a discussion of cervical and lumbar disc disease, as well as gait disorders, and their impact on the elderly, will be presented.

Clinical characteristics of elderly patients with a cautious gait of unknown origin

OBJECTIVE

To evaluate and systematically characterize a group of older adults with disturbed gait of unknown origin.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic in a movement disorders unit.

PARTICIPANTS

Twenty-five patients (mean age 78.4 years) with a disturbed gait of unknown origin were compared with twenty-eight age matched "healthy" controls (mean age 78.2).

MEASUREMENT

Detailed medical history, geriatric and neurological assessments.

RESULTS

Patients walked more slowly (P<0.0001) and with shorter strides (P<0.0001) compared with controls. Muscle strength was lower, and static and dynamic balance and gait performance were worse among the patients (P<0.0001). The patients also tended to be more depressed (P<0.0001),more anxious (P<0.002), had a greater fear of falling (P<0.0001) and had lower scores on the Mini-Mental State Examination (P<0.005). There was no difference in the frequency of cerebellar or pyramidal signs in the two groups. However, neurological testing revealed that extrapyramidal (P<0.0001) and frontal release signs (P<0.0001) were more common among the patients. Neuroradiological findings were rare among the patients and they did not explain the changes in gait speed or fear of falling.

CONCLUSIONS

Older adults with a disturbed gait of unknown origin appear to share common characteristics. They walk more slowly than "healthy" controls with increased unsteadiness and with excessive fear of falling. The extrapyramidal, frontal lobe, and limbic systems apparently play an important role, to different degrees, in what can be viewed as a multisystem neurodegenerative syndrome clearly different from "aging."

Altered fractal dynamics of gait: reduced stride-interval correlations with aging and Huntington's disease

Fluctuations in the duration of the gait cycle (the stride interval) display fractal dynamics and long-range correlations in healthy young adults. We hypothesized that these stride-interval correlations would be altered by changes in neurological function associated with aging and certain disease states. To test this hypothesis, we compared the stride-interval time series of 1) healthy elderly subjects and young controls and of 2) subjects with Huntington's disease and healthy controls. Using detrended fluctuation analysis we computed alpha, a measure of the degree to which one stride interval is correlated with previous and subsequent intervals over different time scales. The scaling exponent alpha was significantly lower in elderly subjects compared with young subjects (elderly: 0.68 +/- 0.14; young: 0.87 +/- 0.15; P < 0.003). The scaling exponent alpha was also smaller in the subjects with Huntington's disease compared with disease-free controls (Huntington's disease: 0.60 +/- 0.24; controls: 0.88 +/-0.17; P < 0.005). Moreover, alpha was linearly related to degree of functional impairment in subjects with Huntington's disease (r = 0.78, P < 0.0005). These findings demonstrate that strike-interval fluctuations are more random (i.e., less correlated) in elderly subjects and in subjects with Huntington's disease. Abnormal alterations in the fractal properties of gait dynamics are apparently associated with changes in central nervous system control.

Neuropeptides and neurotrophin receptor mRNAs in primary sensory neurons of aged rats

Neuropeptides and neurotrophin receptors are regulated in primary sensory neurons in response to axonal injury, and axonal lesions are characteristic stigmata of aging primary sensory neurons. We have therefore examined the expression of neuropeptides and neurotrophin receptor mRNAs in 30-month-old (median survival age) Sprague-Dawley rats to see if similar adaptive mechanisms operate in senescence. The content of neuropeptides was examined with immunohistochemistry (IHC) and in situ hybridization (ISH), and the cellular mRNA expression of neurotrophin receptors was studied with ISH. All of the aged rats had symptoms of hind limb incapacity (posterior paralysis), but fore limbs did not seem affected. The size-distribution of neuronal profiles in cervical and lumbar dorsal root ganglia (DRGs) was similar in aged and young adult (2-3 months old) rats. In aged rats, the DRG neurons showed an increase in both immunolabelling and mRNA content of neuropeptide tyrosine (NPY), as well as an increased cellular expression of galanin mRNA. In the same animals, there were decreased cellular levels of calcitonin gene-related peptide (CGRP; IHC and ISH) and substance P (SP; IHC and ISH), while the difference in neuronal somatostatin (IHC and ISH) was small. The distribution of neuropeptide immunoreactivities in the dorsal horn of the corresponding spinal cord segments revealed a decreased labelling for CGRP-, SP-, and somatostatin-like immunoreactivities (LI) in the aged rats at both cervical and lumbar levels. NPY- and galanin-LI had a similar distribution in aged and young adult rats. NPY-immunoreactive fibers were also encountered in the dorsal column of aged but not young adult rats. ISH revealed that most of the primary sensory neurons express mRNA for the p75 low-affinity neurotrophin receptor (p75-LANR) and that there was no discernible difference between young adult and aged rats. The labelling intensity for mRNA encoding high-affinity tyrosine kinase receptors (TrkA, TrkB, and TrkC) was decreased in aged rat DRG neurons, while the percentage of neuronal profiles expressing mRNA for TrkA/B/C was similar in young adult and aged rats. The changed pattern of neuropeptide expression in primary sensory neurons of aged rats resembled that seen in young adult rats subjected to axonal injury of peripheral sensory nerves and may, thus, indicate aging-related lesions of sensory fibers. Since NPY is primarily present in large and galanin in small DRG neurons, the stronger effect on NPY as compared to galanin expression may indicate that aging preferentially affects neurons associated with mechanoreception (A alpha and A beta fibers) as compared to nociceptive units (A delta and C fibers). Furthermore, the observed changes in neuropeptide expression were most pronounced in lumbar DRGs, that harbors the sensory neurons supplying the affected hindlimbs of the rats.

Increased expression of serotonin transporter messenger RNA in raphe neurons of the aged rat

The action of serotonin (5-hydroxytryptamine; 5HT) in the nervous system is terminated by reuptake of the neurotransmitter into the presynaptic nerve terminal via a plasma membrane-bound transporter protein. Recently, cDNAs encoding serotonin transporter protein were cloned. Using in situ hybridization we have studied the expression of serotonin transporter mRNA in the bulbospinal 5HT system of adult (2-3 months) and aged (30 months) rats. In adult rats, serotonin transporter mRNA labelled neurons were detected in the nucleus raphe obscurus, pallidus and magnus. In all aged rats, the optical density of the serotonin transporter mRNA labelling of individual cell profiles was increased by 20-30% (P < 0.001) when compared with adult rats. Five of the six aged rats studied had various degrees of hindlimb motor dysfunctions. In rats with the most pronounced signs of hindlimb motor dysfunction the number of labelled neurons was increased by 25-75% (P < 0.01) when compared with young adult rats. It is concluded that an increased serotonin transporter gene expression is present in the bulbospinal 5HT system of aged animals.

The serotoninergic bulbospinal system and brainstem-spinal cord content of serotonin-, TRH-, and substance P-like immunoreactivity in the aged rat with special reference to the spinal cord motor nucleus

The 5-hydroxytryptamine (5HT) containing bulbospinal pathway was studied with immunohistochemical (IF) and chemical techniques in 2-3 and 30 months old male Sprague-Dawley rats. The coexisting neuropeptides substance P (SP), thyrotropin-releasing hormone (TRH) and galanin were also analysed. Furthermore, the expression of mRNA encoding aromatic L-amino acid decarboxylase (AADC), prepro-TRH, and preprotachykinin (prepro-SP) was analysed with in situ hybridization (ISH) in the midline raphé nuclei inthe lower brainstem. The results showed a decreased number of axonal 5HT fibers with a normal morphology in the ventral horn of the aged rat lumbosacral spinal cord, and several 5HT immunoreactive (IR) fibers with an aberrant morphology, suggestive of axonal degeneration, were intermingled. This was evident in both the dorsal and ventral horn of the spinal cord. The 5HT-IR fibers with an aberrant morphology usually also contained TRH-and/or SP- and/or galanin-like immunoreactivity (LI) in the ventral horn. These signs of degeneration were clearly less evident in the thoracic and cervical spinal cord segments. Moreover, these changes varied between aged litter-mates. This was in agreement with behavioural signs of motor disturbances, present in about 40% of the aged rats and which in all cases were confined to the hindlimbs. Chemical analyses disclosed significantly lower levels of TRH-LI and, in particular, SP-LI in both the ventral and dorsal quandrants of the spinal cord in the aged rat compared to young adults. The differences were largest in the lumbar regions of the spinal cord. Corresponding analysis of 5HT and 5-hydroxyindoleacetic acid (5HIAA) in the same tissue specimens revealed largely unaltered levels of 5HT and a slight increase in 5HIAA, indicating the possibility of an increased 5HT turnover in the aged rat spinal cord. Neurons in nucleus raphé obscurus and nucleus raphé pallidus were immunoreactive to 5HT, and after pretreatment with colchicine to TRH-, SP-, and galanin-LI as well. There was no obvious difference in number of labeled cells, or labeling intensity, between colchicine-treated young adult and aged rats, although, in the corresponding region of medulla oblongata, chemical analysis disclosed significantly lower levels of 5HT, TRH, and, in particular, SP in untreated aged rats. In contrast, in situ hybridization analysis revealed increased mRNA levels encoding prepro-TRH and prepro-SP in old rats, while mRNA content encoding AADC mRNA was similar in young adult and aged rats.(ABSTRACT TRUNCATED AT 400 WORDS)

A new technique for simultaneous monitoring of electrocardiogram and walking cadence

A new technique for simultaneously recording continuous electrocardiographic (ECG) data and walking step rate (cadence) is described. The ECG and gait signals are recorded on 2 channels of an ambulatory Holter monitor. Footfall is detected using ultrathin, force-sensitive foot switches and is frequency modulated. The footfall signal provides an indication of the subject's activity (walking or standing), as well as the instantaneous walking rate. Twenty-three young and elderly subjects were studied to demonstrate the use of this ECG and gait recorder. High-quality gait signals were obtained in all subjects, and the effects of walking on the electrocardiogram were assessed. Initial investigation revealed the following findings: (1) Although walking rates were similar in young and elderly subjects, the elderly had both decreased heart rate (HR) variability (p < 0.005) and increased cadence variability (p < 0.0001). (2) Overall, there was an inverse relation between HR and cadence variability (r = -0.73). Three elderly subjects with no known cardiac disease had HR and cadence variability similar to those of the young, whereas elderly subjects with history of congestive heart failure were among those with the lowest HR variability and the highest cadence variability. (3) Low-frequency (approximately equal to 0.1 Hz) HR oscillations (frequently observed during standing) persisted during walking in all young subjects. (4) In some subjects, both step rate and HR oscillated at the same low frequency (approximately equal to 0.1 Hz) previously identified with autonomic control of the baroreflex.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigation of gait in elderly subjects over 88 years of age

To evaluate senile gait patterns in octagenarians and nonagenarians, we provided a standardized questionnaire on gait disabilities to 153 elderly subjects over 88 years of age. Subjects represented a relatively healthy subgroup of noninstitutionalized residents who participated in a gerontological survey of all inhabitants of the city of Leiden who were 85 years of age or older. Of the 142 subjects who responded to this questionnaire, 87 persons (61%) claimed distinct diseases as a cause of gait impairment. Forty-two of the remaining 55 persons were investigated neurologically and received a standardized assessment of gait. Twenty-five persons (18% of all responders) had a completely normal gait, whereas a wide spectrum of gait abnormalities--mainly with ataxic features--was encountered in the remaining persons. It is concluded that a surprisingly high number of very old community residents can have a completely normal gait. Gait disorders in this age group are most frequently associated with common distinct diseases. In addition, many elderly have a gait disturbance of variable clinical nature and unclear pathologic basis, which may represent the "idiopathic senile gait."

The syndrome of senile gait

Infrared computed stroboscopic photometry was used to quantify the kinematic profiles of walking in 10 elderly patients with symmetrical neurological disturbances of gait and in 19 age-matched neurologically healthy people. Clinical examination of the patients revealed similar profiles of walking even though their diagnoses were vascular dementia (2), normal pressure hydrocephalus (2), Alzheimer dementia with possible normal pressure hydrocephalus (2), mixed Alzheimer and vascular dementia (1), peripheral neuropathy (1), Alzheimer dementia with parkinsonian features (1), and undetermined (1). Quantitatively, the patients' gait kinematics deviated greatly from control values, but these deviations were statistically attributable to reductions in stride. We suggest that many gait disturbances in elderly people are similar, regardless of etiology, because the characteristics of these gait disturbances are heavily veiled by nonspecific stride-dependent changes that comprise the syndrome of senile gait.

Anatomy of dendrites in motoneurons supplying the intrinsic muscles of the foot sole in the aged cat: evidence for dendritic growth and neo-synaptogenesis

Motoneurons (MNs) supplying the intrinsic muscles of the foot sole (IFS) were studied in the aged cat (greater than 15y). Axon conduction velocity of IFS MNs was 30-40% slower in the aged than in young adult cats. IFS MNs that appeared intact during intracellular recordings and labeling with horseradish peroxidase (HRP) were subjected to anatomical investigation of their dendrites. The results were compared with corresponding data from young adult (less than 3y) cats. The average number of dendrites per IFS MN was twelve in both the aged and young adults. However, the branching was significantly more extensive in the aged cat, thus indicating that proliferation of dendritic branches may occur during the later part of life. Topological analysis revealed a significant difference in the frequency distributions of nodal vertices between young adult and aged cats. In the young adult, the dendritic branching pattern was compatible with trees generated by outgrowth from terminal segments, while in the aged there was a clear indication of collateral outgrowth of branches. The dendritic path distance and the length of terminal branches were similar in young adults and aged. The length of preterminal branches was shorter in the aged, while the combined dendritic length of a dendrite was larger compared to young adults. These data are consistent with the topological data, and add further evidence that the proliferation of branches in the aged cat may also take place from preterminal branches. Light microscopic analysis revealed the presence of "growth cone-like" extensions in the dendrites of the aged cats. Such profiles were not encountered in dendrites from young adults. Electron microscopic observations showed that these "growth cone-like" formations were not artifacts and that they were apposed by numerous axonal boutons, of which a number made synaptic contact. A distinct feature of the extensions was their rich content of mitochondria and membranous elements. It was suggested that these "growth cone-like" formations were sites at which novel synaptic connections are established, and that they may represent the initial stage of an outgrowth of new dendritic branches in the aged cat. Local dendritic branch diameter related closely to the amount of dendritic membrane area located distally in both young adults and aged. Curve fitting disclosed that this relationship was quite similar for both age groups, despite concurrent differences in combined dendritic length and branching degree.

Stride-dependent changes in gait of older people

Infrared computerized stroboscopic photometry was used to measure the kinematic profile of walking of 20 young adults and 20 neurologically healthy elderly people. Compared with the young adults, the elderly exhibited 17-20% reductions in the velocity of gait and length of stride. The elderly also exhibited comparable reductions in the maximum toe-floor clearance, arm swing, and rotations of the hips and knees, but these alterations in gait were attributable to the reduction in stride length, which may have non-neurological causes. The influence of reduced gait velocity and stride length on the other characteristics of walking must be considered when evaluating the pattern of walking in elderly people.

Parkinsonian abnormality of foot strike: a phenomenon of ageing and/or one responsive to levodopa therapy?

1. Normally during walking, the heel strikes the ground before the forefoot. Abnormalities of foot strike in idiopathic Parkinson's disease may be amenable to therapy: objective measurements may reveal response which is not clinically apparent. Occult changes in foot strike leading to instability may parallel the normal, age-related loss of striatal dopamine. 2. The nature of foot strike was studied using pedobarography in 160 healthy volunteers, aged 15 to 91 years. Although 16% of strikes were made simultaneously by heel and forefoot, there were no instances of the forefoot preceding the heel. No significant effect of age on an index of normality of foot strikes was detected (P greater than 0.3). 3. The effect on foot strike of substituting placebo for a morning dose of a levodopa/carbidopa combination was studied in a double-blind, cross-over trial in 14 patients, aged 64 to 88 years, with no overt fluctuations in control of their idiopathic Parkinson's disease in relation to dosing. On placebo treatment there was a highly significant (P = 0.004) reduction in the number of more normal strikes, i.e. heel strikes plus simultaneous heel and forefoot strikes. The effect appeared unrelated to the corresponding difference between active and placebo treatments in plasma concentration of levodopa or a metabolite of long half-time, 3-O-methyldopa (3OMD). However, it correlated negatively (P less than 0.05) with the mean of the 3OMD concentrations. 4. It appears that some abnormalities of foot strike due to Parkinson's disease are reversible. Employing test conditions, designed to provoke abnormalities of foot strike, might be useful in screening for pre-clinical Parkinson's disease.

Characteristic patterns of gait in the healthy old

If the influences of aging processes on gait are to be understood, gerontologists must become better versed in experimental methodology appropriate to locomotion research. They must also begin to conduct experiments that move beyond mere description. Systematic research efforts that are interdisciplinary in nature and that incorporate several types of gait analyses will be needed to discover the causes of adaptations and impairments of gait in the aged. Certainly, this will not be easy to accomplish; however, we hope that the work reported here demonstrates this approach is possible and worthwhile.