5 Discoveries About the Link Between Gait and Cognition

By Suzanne Wagner PT, MPT, LSVT Big Certified

Physical Therapist

A review of Interventions for Aging Gait: Understanding Cognition and Frailty, a MedBridge Course presented by Julie Ries, PT, PhD

In the therapy world, the thinking was that gait issues and cognition issues were two separate issues. When looking at gait, the theory was that instability results in decreased gait speed leading to falls. Cognition was looked at separately from gait, with a clear path from cognitive impairments to dementia.

Now there is a newly emerging view that there are connections between gait issues and cognition issues. Cognitive impairment can result in gait instability and vice versa. Along with that, a patient who suffers a fall or fracture could develop issues with cognition as an effect of the fall. By understanding the connection between gait and cognition we can begin to understand how to address a patient’s needs more effectively.

1. Cognition and gait present with distinct patterns. Verlinden et al. (2014) completed a study of 232 older adults (mean age 66) where the researchers performed cognitive and gait assessments. Cognitive function was assessed by evaluating memory, information processing, fine motor speed, executive function, and global cognition were addressed. Gait analysis was also completed looking at rhythm, variability, phases of gait, pace, tandem, turning, base of support, and global gait pattern. After reviewing their data, they found patterns of presentation correlating cognitive function deficits with distinctive gait dysfunctions. Participants who presented with processing deficits have issues with gait rhythm. Participants with motor speed deficits displayed difficulty with tandem gait. Participants with issues with executive function presented with challenges in maintaining pace, and those with global cognition deficits had issues with variability in gait.
2. Cognitive decline and mobility decline may share similar pathophysiology. Buchman et al. (2011) followed 1,154 community-dwelling adults. Of these 836 had no mobility impairment at the start of the study. They were followed for 4.5 years while researchers monitored their cognitive function and the development of mobility impairments. At the 4.5-year mark, 423 of the 836 who previously had no mobility impairment had developed mobility impairment. Researchers learned that lower levels of cognitive function are associated with increased mobility impairment and declining mobility and that the rate of cognitive decline correlated with declining functional mobility.
3. There are associations between gait speed and cognition in older adult males and females. Best et al. (2016) studied over a nine-year period of 2,876 functioning community-dwelling older adults (mean age 74). Participants were monitored for gait speed and cognitive function. Researchers learned that an early decline in gait speed (years 0-4) predicted a decline in cognition (years 4-9). The correlation between the decline in cognition (years 0-4) was weaker with a decline in gait (years 4-9). The conclusion was that declining gait speed is a precursor to declining cognitive function.
4. There is a direct link between executive function and falls in older adults. Mirelman et al. (2012) performed a five-year prospective study that linked fall risk to cognitive function. They followed 256 community-living older adults (mean age 76) who were dementia-free and had good mobility. They performed baseline cognition and mobility assessments and tracked falls data for five years. They found that executive function (EF), attention index, and dual-task gait variability were associated with future fall risk. They concluded: “…the risk of future falls was predicted by performance on EF and attention tests conducted five years earlier. The present results link falls among older adults to cognition, indicating that screening EF will likely enhance fall risk assessment and that treatment of EF may reduce fall risk.”
5. There is a “dual-task cost” for performing functional activities—Patients have a finite amount of attention available to them in order to complete a task. Walking requires a level of attention that is different from attempting to walk while carrying a glass of water (superimposed activity). Patients can run into trouble when they are required to perform both tasks at the same time and they do not have the attention reserve to complete both, this is the dual-task cost. Al-Yaha et al (2011) found dual-tasking impacts gait parameters including decreased speed, decreased cadence, decreased stride length, increase stride time and variability and concluded that the calculated “dual-task costs” for activities, increased complexity of cognitive activity there were increased dual-task costs, the “cost” is how much performance declines when a cognitive demand is applied.

A quick summary of the above research shows that there is an inter-relatedness between gait and cognition. The rate of change of cognitive function in older adults is associated with a change in mobility function and vise versa a decline in gait correlates to cognitive decline and can predict a decline in function. Finally, older adults with lower executive function (EF) scores fall sooner and more often than those with higher EF scores.

As a therapist, what can I do? When assessing a patient you look at the whole picture. Whether a patient has a diagnosis of dementia or not, take the time to assess cognition. Perhaps that motor planning issue you are seeing in a patient isn’t actually a motor planning issue but an executive function issue or the dual-task cost is too great.

If you are identifying a cognitive function issue, get the other disciplines involved. If the patient is receiving OT already, have a discussion with the OT about dual-task training and incorporating cognitive therapy into their activities. Speech therapy is an excellent resource; refer them for cognitive therapy. It is important to assess the patient’s ability to perform dual-task activities and incorporate that into our training keeping in mind the dual-task cost.