Frontal gait disorder

Walking disorders are common in the elderly. Sometimes the changes to the person’s walking cannot be explained by neurological causes, such as stroke, or non-neurological causes, such as arthritis.

Changes to walking that are not due to any obvious cause have previously been considered ‘normal’ in older adults. More recently however, research has shown that these changes are often due to changes in the person’s brain.

This form of walking disorder presenting in the elderly is called Frontal Gait Disorder (FGD). Although there’s currently no treatment that can stop FGD from progressing, there are therapies available that can improve the person’s walking.

The typical changes to walking due to FGD include:

  • walking with short, shuffling steps with feet wide apart
  • arm swing remains normal
  • difficulty starting walking as FGD progresses
  • feeling unsteady

These changes result in

  • difficultly walking at home and in the community
  • difficulty with participating in community activities such as shopping, attending social events
  • increased falls risk
  • loss of function and independence with help needed for daily activities, personal care, home care

Diagnosis of frontal gait disorder

A neurologist specialising in movement disorders is the recommended medical person to see when seeking a diagnosis.

The diagnosis of FGD can be difficult to make as the person is usually elderly and may therefore have other medical problems, such as arthritis, that may cause their walking to change.

A neurologist who is an expert in movement disorders will be able to eliminate other causes of the walking changes to arrive at the diagnosis of FGD.

It is also important to see a neurologist as there are treatable disorders, such as normal pressure hydrocephalus and frontal meningioma, that present as FGD.

Examples are normal pressure hydrocephalus and frontal meningioma.

Brain scans usually show changes to various parts of the deep part of the brain, called the white matter, in FGD.  Though brain scans on their own may not lead to a diagnosis of FGD, they can help support the diagnosis when the person is also noted to walk with short shuffling steps with normal arm swing and  no facial masking nor other upper body Parkinsonian symptoms..

FGD is commonly misdiagnosed as Parkinson’s disease as the walking pattern is similar in both disorders. However, when a person with FGD is trialled on Parkinson’s medications, their walking generally does not improve.

Causes of frontal gait disorder

The causes of FGD remain unclear.  Cardiovascular risk factors, such as high blood pressure and high cholesterol, have been linked to vascular changes in the white matter of the brain and subsequent changes to walking.

The changes in the deep white matter of the brain disrupt the signals travelling between the basal ganglia (the area of the brain that runs well learned automatic movements such as walking)  and the motor or movement control parts of the outer part of the brain. Unlike Parkinson’s disease, the basal ganglia are not directly affected in FGD however interference to these pathways results in similar symptoms i.e. slow, shuffling steps.

The walking of a person with FGD will continue to worsen over time due to the ongoing vascular changes in the brain.

Symptoms of frontal gait disorder

The most common symptoms in the early stages are the short, shuffling steps.

As FGD progresses, balance may worsen and the person can feel unsteady when walking. Fear of falling can develop, further limiting the person’s walking.

FGD is also associated with changes in cognition, the mental processes needed to learn, reason and remember.

Walking and cognitive changes can progress rapidly in FGD.

As the disease progresses, people living with FGD are likely to need assistance from family or carers for day to day activities. Equipment and home modifications can also help the person manage their daily tasks.

It is common for the person to having difficulty starting walking as the disorder progresses. Assistance of another person plus the use of a walking frame becomes essential to avoid falls and injury when walking.

Unlike other Parkinsonian syndromes, speech and swallowing are not affected.

Changes in cognition (memory and thinking) are common in FGD but may also be reflective of their age and not just the underlying pathology causing FGD.

Treatment of frontal gait disorder

Currently there is no treatment available to stop or slow the progression of FGD.

There are therapies are available to manage the mobility, balance and activities of daily living problems.

Medical treatment

There are no medications that can improve the motor symptoms or stop the progression of FGD.

It is important that a person presenting with FGD symptoms sees a neurologist specialising in movement disorders as there are other treatable conditions that may be misdiagnosed as FGD.

Walking, balance, falls and posture

A physiotherapist specialised in movement disorders such as FGD can tailor an exercise program that meets the needs of the person.

A physiotherapist can assess walking and balance problems and recommend ways to improve mobility and safety.

An occupational therapist can assess the person at home and suggest ways to improve safety, both inside and outside the home.

A physiotherapist can advise on ways to help the person walk safely, reduce risk of falls and remain independent as long as possible.

The physiotherapist can teach strategies that use attention to increase the person’s step length and walking speed thereby making it easier to manage at home and in the community. Attentional strategies can improve walking dramatically in the early stages of FGD.

As FGD progresses, cognition generally deteriorates and the person has difficulty using attentional strategies effectively.

Compensatory approaches, such as using a walking frame, are usually the most effective way to improve walking and safety at this stage.

An occupational therapist may come to the home to advise on ways to improve mobility and safety in the home and the community.

An occupational therapist can advise on safety aids to suit the needs of the person, such as rails next to steps, equipment for the shower and toilet. If home modifications are required, they can help with the planning of them.

There are various funding bodies that can fully or partially cover the cost of some home modifications and adaptive equipment such the State Wide Equipment Program (SWEP). An occupational therapist can advise you on how to apply for funds to assist with the costs if required.

Social impact

The effects of FGD will impact on the person and their family.

Coping with the diagnosis and managing caregiver burden as the disorder progresses can impact on the quality of life of both the person with FGD and the caregiver.

A social worker has the expertise to assist the person with FGD, their caregiver and family negotiate the challenges.

The person may be overwhelmed on receiving the diagnosis of FGD causing their mood to be low or to feel depressed. A social worker can help them to cope with these feelings.

Social workers are highly skilled professionals who can assist the person with FGD and their caregivers and family by:

  • providing a range of different therapy’s like counselling
  • assistance with linking to other support services
  • directing you to financial support services
  • information provision of entitlements for care packages
  • help to facilitate suitable respite arrangements for the caregiver
  • assistance and support with navigating the pathway to permanent residential care if the need arises

Cognition and behaviour

Cognition refers to our mental processes and includes the ability to learn, to reason and remember.

Worsening of cognition may make the person feel less confident and anxious.

Behaviour changes may develop and include apathy, impulsive behaviour, mood swings.

It is important that the person with FGD, their caregiver and family speak to the neurologist about these changes.

There are specialists, such as a neuropsychologists, who can assess the severity of these changes. The information gained from the assessment is important in ensuring the person receives the best care and advice to help them manage these changes.

A neuropsychologist can assess cognition when the person is experiencing problems that are interfering with their ability to live independently. The neuropsychologist will suggest strategies to use to address the underlying cognitive problems.

An occupational therapist specialised in movement disorders such as FGD also has the skills to train the person in the use of a range of strategies such as using attention, breaking activity into small parts before performing, use of cue cards, use of lists.

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