Gait and Balance Dysfunction in Adults.

Determining the precise cause of gait dysfunction in adults is often difficult because of the multifactorial nature of the disorder. Additionally, elderly patients have other comorbidities that further complicate their diagnosis. A proper history and physical examination, however, often allow the clinician to arrive at the correct diagnosis. Once a diagnosis is reached, appropriate therapeutic decisions can be made. Patients presenting with Parkinsonism need a thorough evaluation to rule out potentially reversible conditions, such as normal pressure hydrocephalus. Patients with idiopathic Parkinson's disease usually develop gait difficulty and freezing episodes late in the course of the illness. Another important cause of gait disturbance in adults is the cerebellar ataxias. Among the sporadic forms, gluten sensitivity is an important consideration. Identification of this entity is important, because the disease process can be halted with a gluten-free diet. Another group is the paraneoplastic ataxias, which can often be diagnosed in the proper clinical setting. Most of the adult-onset hereditary ataxias are autosomal dominant conditions. Except for the episodic ataxias, treatment of these conditions has been disappointing. Mixed results have been obtained with the use of amantadine, buspirone, and 5-hydroxytryptophan. Physical therapy plays an important role in the gait rehabilitation of these patients. Over the past several years, researchers have developed a greater understanding of motor control and how it relates to freezing. Clinicians can now train patients to use external cues to overcome their motor blocks. Another important advance has been the development of subthalamic nucleus deep brain stimulation in the treatment of patients with troublesome peak dose dyskinesia and other motor fluctuations. Subthalamic nucleus deep brain stimulation should be considered when best medical treatment fails. Cortical myoclonus can be treated with levetiracetam, which has US Food and Drug Administration approval as an antiepileptic agent. It has been quite effective in the treatment of myoclonus and should be considered when other medications fail.