In an older adult with gait disturbance, dysphagia, and recurrent falls, what urgent work‑up and management steps are recommended?

Urgent Work-Up and Management for Older Adult with Gait Disturbance, Dysphagia, and Recurrent Falls

This presentation demands immediate neurological evaluation to exclude life-threatening conditions—particularly brainstem stroke, neurodegenerative disease, or normal pressure hydrocephalus—because the combination of gait disorder with dysphagia signals central nervous system pathology that can rapidly progress to aspiration pneumonia, complete immobility, or death. 1

Immediate Red-Flag Assessment

The combination of walking difficulty and swallowing problems is not a typical fall-risk presentation and requires urgent investigation for:

• Brainstem or bilateral hemispheric stroke – dysphagia combined with gait ataxia suggests posterior circulation involvement 2, 3
• Normal pressure hydrocephalus (NPH) – the "magnetic" or "glued to floor" gait pattern is the cardinal sign; look specifically for wide-based shuffling, difficulty initiating steps, and postural instability 4
• Parkinson's disease or atypical parkinsonism – progressive supranuclear palsy commonly presents with both dysphagia and falls 2, 5
• Amyotrophic lateral sclerosis (ALS) – bulbar-onset ALS causes dysphagia early, with gait impairment from upper and lower motor neuron involvement 6
• Myasthenia gravis or Lambert-Eaton syndrome – fatigable weakness affecting both swallowing and ambulation 3

Critical History Elements

Document the following specific details immediately:

• Time spent on the ground after any fall—prolonged downtime (>1 hour) indicates severe weakness or inability to self-rescue and predicts rhabdomyolysis risk 1
• Loss of consciousness or syncope during falls—suggests cardiac arrhythmia, seizure, or vertebrobasilar insufficiency 1, 7
• Dysphagia characteristics: difficulty with solids versus liquids (oropharyngeal vs. esophageal), coughing during meals, nasal regurgitation, or voice change (bulbar involvement) 2
• Progression timeline: acute onset (<72 hours) mandates stroke protocol; subacute (weeks) suggests NPH or neurodegenerative disease; chronic (months) points to Parkinson's or polyneuropathy 2, 3
• Cognitive symptoms: memory problems, urinary incontinence, and gait disorder form the NPH triad 4
• Medication list: psychotropic drugs (odds ratio 1.7 for falls), anticholinergics, sedatives, and polypharmacy ≥4 medications 7, 1

Mandatory Physical Examination

Perform a complete head-to-toe examination—failure to do so misses occult fractures and subdural hematomas 1:

• Gait observation: look for specific patterns—

  • Magnetic/shuffling gait with wide base and difficulty turning = NPH 4
  • Parkinsonian gait with reduced arm swing, festination, freezing = parkinsonism 2, 5
  • Ataxic gait with irregular steps and truncal instability = cerebellar or sensory ataxia 3, 5
  • Hemiparetic gait with circumduction = stroke 8
  • Neuropathic gait with foot drop or steppage = peripheral neuropathy (risk ratio 1.94 for falls) 8

• Neurological examination:

  • Cranial nerves: assess for bulbar signs (tongue fasciculations, palatal weakness, dysarthria) suggesting ALS or brainstem lesion 6, 2
  • Motor: proximal weakness, fasciculations, spasticity, rigidity 1, 3
  • Sensory: vibration and proprioception loss (posterior column dysfunction) 1, 8
  • Reflexes: hyperreflexia with upgoing toes (upper motor neuron), or areflexia (peripheral neuropathy) 3
  • Cerebellar signs: dysmetria, dysdiadochokinesia, nystagmus 5

• Orthostatic vital signs: measure blood pressure supine and after 1 and 3 minutes standing—drop ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension 1, 7

• Cognitive screening: use Mini-Cog or Memory Impairment Screen—cognitive impairment has relative risk 1.8 for falls and is part of NPH triad 1, 7, 4

Urgent Diagnostic Testing

Maintain a low threshold for the following 1:

• Brain MRI with and without contrast (preferred) or CT head—identify stroke, NPH (dilated ventricles with normal pressure), subdural hematoma, or mass lesions 4
• ECG—exclude arrhythmias, heart block, or ischemia causing syncope 1, 7
• Complete blood count—anemia or infection 1
• Comprehensive metabolic panel—electrolyte disturbances, renal failure, hypoglycemia 1
• Vitamin B12 and thyroid function—reversible causes of neuropathy and cognitive impairment 9, 7
• Creatine kinase—if prolonged downtime, to assess for rhabdomyolysis 1
• Swallow evaluation (bedside or videofluoroscopy)—aspiration risk assessment is mandatory before oral intake 2

If NPH is suspected (gait disorder + cognitive impairment ± urinary incontinence with dilated ventricles on imaging):

• Perform lumbar puncture with removal of 30–50 mL cerebrospinal fluid—transient gait improvement within 2–24 hours confirms diagnosis and predicts shunt responsiveness 4

If ALS is suspected (progressive bulbar and limb weakness with fasciculations):

• Obtain EMG/nerve conduction studies and refer urgently to neurology—riluzole 50 mg twice daily (taken 1 hour before or 2 hours after meals) is indicated and may prolong survival 6

Comprehensive Medication Review

All patients must have medications reviewed and modified 1:

• Deprescribe or reduce psychotropic medications (benzodiazepines, antidepressants, antipsychotics)—these carry odds ratio 1.7 for falls 7, 1
• Review vasodilators, diuretics, antiarrhythmics (class 1a agents have odds ratio 1.6), and digoxin (odds ratio 1.2) 7
• Polypharmacy ≥4 medications independently increases fall risk and requires systematic reduction 10, 1, 7

Disposition Decision

Admit to hospital if:

• Patient cannot pass the "Get Up and Go" test—rising from chair, walking 3 meters, turning, and returning safely 1, 7
• Dysphagia with aspiration risk—requires NPO status, IV hydration, and swallow evaluation 2
• Unsafe home environment or inability to self-rescue after falls 1
• Acute neurological findings requiring urgent intervention (stroke, NPH, severe weakness) 2, 4

All admitted patients must receive evaluation by physical therapy and occupational therapy 1.

Post-Discharge or Outpatient Management (if safe for discharge)

• Expedited neurology follow-up within 1–2 weeks for definitive diagnosis 1, 7
• Supervised exercise program with balance and gait training—reduces fall incidence by 23% (relative risk 0.77) when performed 3 sessions per week for ≥12 months 7
• Home safety assessment to remove tripping hazards, improve lighting, and install grab bars—reduces falls by 26% when combined with exercise and medication review 7
• Vitamin D supplementation 800 IU daily for ≥12 months—number needed to treat is 10 to prevent one fall 9, 7
• Speech therapy referral for dysphagia management and aspiration precautions 2

Critical Pitfalls to Avoid

• Discharging a patient who fails the "Get Up and Go" test without further evaluation markedly increases immediate fall and injury risk 1, 7
• Attributing symptoms to "normal aging" without investigating reversible causes (NPH, B12 deficiency, medication effects, depression) delays life-saving treatment 9, 2
• Omitting swallow evaluation in a patient with dysphagia leads to aspiration pneumonia and death 2
• Performing only a focused examination rather than complete head-to-toe assessment misses occult fractures, subdural hematomas, and other serious injuries 1
• Failing to recognize NPH—this is one of the few reversible causes of dementia and gait disorder; untreated patients progress to wheelchair dependence and institutionalization 4