As with the musculoskeletal examination, your evaluation began with the 10-Minute Geriatric Screener. Carefully assess memory and affect.
Pay close attention to gait and balance, particularly standing balance; timed 10-foot walk; stride characteristics like width, pace, and length of stride; and careful turning. A recent study of neurologic versus non-neurologic (primarily hip and knee orthopedic) gait disorders showed that neurologic disorders like parkinsonian; sensory ataxic; spastic; higher level gait; and, particularly, multiple neurologic gait disorders tripled the risk for recurrent falls. Investigators are looking at the neurobiology of gait disorders as markers of preclinical dementia and other neurologic conditions that may lead to earlier diagnosis and new preventive strategies.
When gait abnormalities are detected, pursue a more detailed neurologic examination. Distinguishing neurologic changes of aging from abnormal findings is challenging, as neurologic abnormalities without identifiable disease are common in the older population and increase with age, occurring in up to 50% of older adults. Examples of age-related abnormalities include unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, presence of the snout and grasp reflexes, and decreased toe vibratory sense.
Examine for evidence of Tremor, Rigidity, Akinesia, and Postural instability, or TRAP, which are several of the most common features of Parkinson disease. Also look for bradykinesia, the most characteristic clinical sign, and micrographia, shuffling "freezing" gait, and difficulty rising from a chair.
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