Mobility | Description

Most dementias will at some point in their course, affect areas of the brain that are responsible for movement and balance Balance
The ability to sit or stand upright without falling over or slumping into a potentially dangerous position.. Usually, families will note that the person walks more slowly. After a while they will commonly describe the person's walking as being "uncoordinated". These aren't bad descriptions, but they are not what doctors say, because we tend to think about symptoms and signs of dementia (or any neurological Neurological
Relating to neurology. disease) in terms of which part of the brain is affected.

When it comes to problems with walking in dementia, unless it is due to a stroke Stroke

Blood supply to the brain is interrupted, usually by a blood clot. As a result, a portion of the brain can die from not receiving enough blood and oxygen.  

 

that gives rise to paralysis Paralysis
An inability to move part of the body. , or other less common, specific, local causes, doctors tend to approach the problem by considering two types of problems. One has to do with slowing, and the other with how the brain integrates all the information that is needed for precise movement.

The first problem - slowing - typically is part of a syndrome called "parkinsonism". The term is related to, but slightly different from parkinson's disease Parkinson's disease
A progressive, neurodegenerative disease characterized by the death of neurons in the brain. The disease has been linked to a lack of the neurotransmitter dopamine which has consequences such as tremors, speech impediments, movement difficulties, and often dementia later in the course of the disease.. Parkinson's disease affects movement in many ways, but traditionally these are grouped under four headings: tremor (a rhythmic form of shaking); slowness of movement (the fancy term is bradykinesia) muscle Muscle
Body tissue that contracts to produce movement or force. stiffness (the technical term that doctors use is rigidity; we use it to distinguish it from the stiffness seen with a stroke, which is called spaticity) and the tendency to fall (we call a fall a fall, but we call the tendency to fall postural instability). So one type of mobility Mobility
To be able to move about either on your own or with the use of a walking aid. problem for a person with dementia is slowing, as an aspect of parkinsonism. Other signs of parkinsonism that have to do with walking are that the steps shorten, the posture becomes stooped, the space between the feet (so-called "base of the gait Gait
A manner of walking, running or moving on foot.") narrows, and there is less arm swing. When the person turns, they no longer pivot on their heels, but instead turn in a series of short steps. During the turns, their balance can become unstable; they are especially likely to fall backwards. Another related problem is that the person can seem to freeze in place when they walk through a door frame.

The second type of problem overlaps a little with the first, and is commonly described by families as the person they care for being "uncoordinated". (The technical term that doctors use for this is "apraxia"; we use "uncoordinated to mean a problem with a structure at the back of the brain called the cerebellum. And of course, when we really start in on talking about incoordination, we quickly switch over to another term, called ataxia. Even so, it makes me hesitate to use the term "incoordination" when what I mean is apraxia, not ataxia. What families typically see in the person who is having trouble walking that goes beyond simple slowing and parkinsonism is that the person with dementia first has problems starting to walk. The starting to walk (the technical term is "gait ignition" can be part of parkinsonism, or a sign of apraxia. Either way, sometimes 'sensory tricks' can help.

Very early in the course of apraxic walking in dementia, a cane or a walker can help. It is common to see a person go from a slow, cautious gait, to an almost normal walking pattern simply by taking up a cane. In fact, I have often seen the cane work when the person holds it in their hand, without the can actually touching the floor. Later, however, a more common picture is the person with dementia requiring physical "hands on", such as touching by another person to start walking or to rise out of a chair. When the problem is first one of getting started, families often comment that the person they care for does not need anything more than a touch to get out of the chair, but can't seem to get out of the chair without it.

There are types of problems with starting walking (with gait ignition disorders) that respond to a variety of what is known by the trade as "sensory tricks". For example, vigorously stroking the leg that you want the person to start moving, or seeing if they can lift their feet up and down to march in place, or seeing if they can step over something to start - a line, or sometimes you can put one foot in front of theirs and ask them to step over it. Many people who have been in the armed services will respond to the command "quick march" spoken softly into their ear. Frustratingly, although some tricks often work, none of them work all the time.

It is also important to remember that people with dementia can have problems with walking that are not due to the dementia itself. Exhaustion can limit how far a person can walk, as can pain. Sometimes pain can reflect an unattended problem in foot care. Usually, a doctor or physiotherapist Physiotherapist
A health professional who assesses a person's physical function and specializes in physical methods of treatment to return to health. can tell just by looking at how someone walks, whether the problem is neurological or due to pain, and if due to pain, whether it is a problem of the hip, the knee, or the ankle/foot.

To sum up, common problems of mobility in a person with dementia are:

Problem		Common Causes
Walks more slowly		Parkinsonism
Walks with a narrow base		Parkinsonism
Cannot start walking		Parkinsonism or apraxia
Cannot continue walking/ can only walk short distances		Exhaustion, pain or apraxia
Freezes in the door frame		A classic sign of parkinsonism
Walks with a limp		Pain in the hip, knee, ankle or foot; stroke

 

This is not meant to be an exhaustive list, just to help summarize the points made above. An exhaustive list would have to include, amongst other things, walking with a broad base, or with a "scissors" gait, in which the knees come together but the feet are apart, or various types of problems seen when the cerebellum is affected, or disorders of walking that are accompanied by a lot of extra movements, just to name a few. The point is that abnormalities of gait are generally explicate, even if the explanation does not often give rise to treatment.


Quick tips:

• The person you care for may be able to walk, but only for limited distances. This could be due to exhaustion and muscle fatigue, and related to damage in the brain.
• The person you care for may require a mobility aid Mobility aid
  See walking aid. for support in order to feel secure. These aids could range from a walking cane to a wheel chair, or they might even need a person to assist them.
• The person you care for may require you as a caregiver to physically help them when they are mobile, or they may just need the security of your presence to give them the confidence they require to walk.
  
  

Treatment of mobility problems in dementia


For all the different types of problems, there are only just a few treatments. Sometimes a physiotherapist can help, especially if a walking aid Walking aid
A device that assists a person in being mobile. It can provide the balance necessary to make them comfortable enough to walk, like a cane, or it can be a wheelchair to assist them in moving when walking is not possible. is going to be used for the first time. A physiotherapist can also help by showing exercises that can strengthen muscles, especially those around the hip, which help prevent falling. Many people with dementia can still learn to do simple repetitive exercises, and get some enjoyment from it. Physiotherapists who work with dementia patients commonly observe that as the person exercises more, they exercise better, and often seem more engaged. Families commonly notice this too.

It is controversial whether treatment for Parkinson's disease works for people who have parkinsonism in dementia. Some things are clear. If the parkinsonism is due to or made worse by medications (especially neuroleptic Neuroleptic
A class of drugs used to treat psychosis. or antipsychotic medications) these need to be used in the lowest possible doses, or even discontinued if that is possible. It is also clear that the motor parkinsonism of Parkinson's Disease Dementia should be treated.

In Parkinson's disease, some drugs work by lowering the amount of the brain chemical (neurotransmitter Neurotransmitter

A specialized chemical messenger such as acetyl choline, that sends a message from one nerve cell to another. Neuortransmitters are responsible for the communication within the brain and also between the brain and other parts of the body.

 

) acetylcholine. These drugs must be avoided in people with dementia. Most drugs, however, work by increasing the amount of the brain chemical (neurotransmitter) dopamine Dopamine
A neurotransmitter found in the brain that has been associated with Parkinson's disease.. If a dopamine preparation is to be used, this needs to be done with great care, as a side effect Side effect
An undesired effect of a drug treatment that may range in severity from barely noticeable, to uncomfortable, to dangerous. can be hallucinations or delusions. This dilemma arises most often in lewy Body dementia where the parkinsonism is most classically like Parkinson's Disease, but where hallucinations can be a very difficult problem.

Sometimes, in people with Alzheimer's disease Alzheimer's disease
A neurological disease that affects memory and behaviour. It is characterized by beta-amyloid plaques and neurofibrillary tangles in the brain. There is no known cause but genetics and lifestyle are thought to play a role., mobility problems due to apraxia can improve by treatment with a cholinesterase inhibitor Cholinesterase inhibitor
A drug which stops the effect of cholinesterase (the first-line drugs for treating Alzheimer's disease). In the days when cholinesterase inhibitors were first being used, I saw this many times, because it was common to see people with moderate dementia who had never been treated. Now that treatment is so widespread, I see it less often. Where I now see it most is when patients who have been on one cholinesterase inhibitor are switched from that to another, or sometimes when memantine Memantine
An NMDA receptor antagonist used to treat moderate to severe dementia. It effects the glutamate neurontransmitter, not the acetyl choline like many other dementia drugs do. is added.


When mobility impairment means the person can no longer walk

As the person you care for becomes more and more immobile, they might no longer be able to walk. Sometimes this comes on suddenly, after an acute Acute

When something is "acute", it means that it is generally short in duration and usually severe.

illness that has required the person to be in hospital. mobility can be lost quickly on that setting, and sometimes it is very difficult for rehabilitation to occur. Problems with mobility are a common reason for a person with dementia to be moved to a nursing home. Care for a person with dementia who is immobile enough to be bedfast is very difficult. Many other problems go with it, including constipation Constipation
Abnormally delayed or infrequent passage of dry hardened feces. and blood clots. Pneumonia Pneumonia
Inflammation of the lungs that results after bacterial, viral or fungal infection. occurs more often. Pressure sores Pressure sores
Areas of injured tissue and skin. It is caused by lying or sitting in one position for too long. As a result there is a lot of pressure on this part of the body, and blood flow to this area is decreased. Common areas for pressure sores include elbows, heels, and back of the head. can also be seen, and even tough larger pressure ulcers Pressure ulcers
See pressure sores. present as failure of care, smaller ones can develop quickly and insidiously, especially in people whose circulation is poor.For most people with dementia, being bedfast signals the terminal phase. In that phase, it is appropriate to consider palliative Palliative
Treatment that relieves or reduces uncomfortable symptoms such as pain, but does not provide a cure. care.


Other notes on mobility impairment

Mobility impairment occurs more often in some types of dementia than in others. People with Frontotemporal dementia Frontotemporal dementia
A type of dementia that mainly affects the frontal lobe causing a problem in executive function tasks. can show rigidity of movement as the dementia progresses. It is characteristic of Lewy Body dementia, Parkinson's disease dementia, and a group of dementias associated with so-called "parkinson-plus" disorders, such as multiple systems atrophy Atrophy
The shrinkage of tissue or muscle., progressive Progression
A disease that is increasing in severity; going from bad to worse over time. supranuclear palsy and a related disorder called corticobasal degeneration Degeneration
Deterioration, usually of tissue, to a lower or less functional form. (CBD). Frontotemporal dementia sometimes is accompanied by Amyotrophic lateral Sclerous (ALS), so that immobility occurs early in the course of their illness.


What's new with mobility and balance?

One of the most active areas of reaearch amongst people who study how the brain controls movement is that sometimes mild parkinsonism - usually mild slowing - can be the very first sign that a dementia might be starting. Slow movement can preceed other signs for up to five years. The area is challenging however, because as people age, many slow down for a variety of reasons, and not everyone who is slow gets dementia. Even amongst people with parkinsonism, it only increases the risk. It does not mean that dementia is inevitable. The hope amongst people who are doing this research is that if it is an early sign of dementia, it can be treated in some way so that the dementia can be prevented. Several groups are actively engaged in this research worldwide. One respected researcher whose work can be looked at i s Richard Camicioli at the University of Alberta.

 

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