Gait abnormalities or unsteadiness is a common presenting complaint, especially in older patients. It may be a trivial complaint with no underlying pathology or herald a mores serious illness. The concept of 'off legs' usually refers to elderly patients who were previously mobile and active with a sudden deterioration. The cause of 'off legs' is usually an acute illness, e.g. chest infection, urinary tract infection. This article is primarily focused on walking difficulties in adults.

Epidemiology

One third of patients over the age of 65 years will report difficulties with walking.¹

Assessment

History

• Patients may complain directly of problems with walking or simply of unsteadiness.
• It is important to clarify exactly what the patient feels, e.g. which aspect of walking is difficult.
• Ask about falls - when was the last fall, how frequent are they, any syncope or presyncope symptoms?² Please see separate article Recurrent Falls for full details (including management).
• Also, determine duration of problems.
• A full review of systems is required, especially looking for cardiac or neurological disease.
• Ask specifically for features suggestive of cord compression, e.g. urinary retention, sensory and/or motor loss.
• Take a full drug history, especially as the aetiology may relate to polypharmacy or drug side-effects.

Examination

• Pulse rate, rhythm, volume and presence or absence of carotid bruits.
• Blood pressure including postural hypotension.
• Cardiovascular examination looking particularly for murmurs, e.g. aortic stenosis.
• Full neurological examination looking for pyramidal, extrapyramidal and cerebellar dysfunction.
• Do not forget the possibility of fractures and injuries - look for leg asymmetry and test the spine and lower limbs for tenderness.
• Examine the gait - asymmetrical or symmetrical problems, presence of waddling gait, broad-based gait, scissoring gait (bilateral leg spasticity), or ataxia.³

Causes and differential diagnosis

Causes of difficulty in walking

Causes of difficulty in walking can be broad and the following table lists some of these:

Causes of 'off legs'

As mentioned above, 'off legs' usually presents in elderly patients and can be interpreted in various ways. This ranges from unsteadiness and difficulty with walking to dizziness or lethargy. The exact meaning should be sought during the assessment of the patient.

The causes of 'off legs' are usually acute and some causes include:

• Urine or chest infections
• Dehydration
• Neurological causes, e.g. head injury, cord compression/cauda equina syndrome
• Orthopaedic causes, e.g. fractures (consider especially in elderly patients with osteoporosis who can fracture their neck of femur without major trauma)
• Metabolic abnormalities, e.g. hyponatraemia, hypercalcaemia, hypoglycaemia or hyperglycaemia
• Alcohol, drug or medications, especially as there are risks of polypharmacy in elderly patients
• Hypoxia

Investigations

These should be guided by the history and examination and may include cerebral imaging, e.g. CT or MRI scanning and blood tests, e.g. thyroid function tests, syphilis serology, etc.

Management

This is directed towards the underlying cause. If the cause is multifactorial then a multidisciplinary approach may be appropriate, e.g. physiotherapist, occupational therapists and allied healthcare professionals.

Also see articles dealing with recurrent falls and prevention of falls in the elderly.

Document references

1. Gillespie L; Preventing falls in elderly people. BMJ. 2004 Mar 20;328(7441):653-4.
2. Ganz DA, Bao Y, Shekelle PG, et al; Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. [abstract]
3. Kumar P; Clarke M; Clinical Medicine, 6th Ed, (2005). WB Saunders: London.

Acknowledgements