Senile march in small steps

Specialty: Geriatrics.

• march a petits pas
• hypokinetic senile gait
• shuffling wandering
• broad-based gait of the elderly

Why it occurs

• Massive leukoaraiosis and multiple lacunar infarcts in the basal ganglia and frontal white matter (vascular parkinsonism)
• Normal pressure hydrocephalus (Hakim-Adams syndrome) with alteration of periventricular motor fibers
• Idiopathic Parkinson's disease or parkinsonism induced by dopaminergic blocking drugs (neuroleptics, antiemetics)
• Severe bilateral osteoarthritis of the hips or knees with joint pain and mechanical limitation of range of motion
• Cervical spondylotic myelopathy associated with spasticity and weakness in the lower limbs

Initial workup

Magnetic Resonance (MRI) of the skull to evaluate the Evans index (ventricular dilation), rule out hydrocephalus and quantify the burden of white matter vascular lesions (Fazekas scale); AP radiographs of the pelvis, hips, and both knees; assessment of walking speed over a 4-meter distance (values ​​<0.8 m/s suggest fragility and high risk of falls); large-volume lumbar puncture evacuation test (Tap Test) to assess temporary improvement in gait if normal pressure hydrocephalus is suspected.

Standard management

• Levodopa/Carbidopa — start with very low doses of 100 mg/25 mg, half a tablet orally three times a day, increasing progressively according to tolerance and motor response, monitoring orthostatic blood pressure and the appearance of hallucinations
• Memantine — 5 mg orally per day, with weekly increases up to 20 mg per day if moderate-severe vascular dementia associated with white matter lesions coexists
• Optimized analgesia with paracetamol to minimize limiting joint pain and facilitate gait rehabilitation.