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Fortschr Neurol Psychiatr 2012; 80(5): 260-266
DOI: 10.1055/s-0031-1299428
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© Georg Thieme Verlag KG Stuttgart · New York

Gangstörungen im Alter: Perspektiven der symptomatischen Therapie

Gait Disorders in the Elderly: Prospects for a Symptomatic Therapy
K. Jahn
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Publication History

Publication Date:
07 May 2012 (online)

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Zusammenfassung

Gangstörungen gehören zu den häufigsten Leitsymptomen in der Neurologie. Im Alter kommen oft mehrere Faktoren als Ursache von Gangunsicherheit und chronischem Schwindel zusammen. Relevante pathogenetische Faktoren sind sensorische Defizite (visuell, vestibulär, somatosensorisch), neurodegenerative Prozesse (kortikal, extrapyramidal-motorisch, zerebellär), toxische Einflüsse (Medikamente, Alkohol) und Angst (primär oder als Folge von Stürzen). Die Einschränkung der Mobilität führt zu einer erheblichen Minderung der Lebensqualität; assoziierte Stürze erhöhen Morbidität und Mortalität. Die Untersuchung betagter Patienten mit dem Leitsymptom „Gangstörung“ sollte die Identifizierung der spezifischen Defizite zum Ziel haben. So kann auch bei multifaktorieller Genese eine gezielte Therapie erfolgen. Neben der Behandlung der Grunderkrankung besteht der Bedarf für wirksame symptomatische Therapieoptionen, insbesondere bei degenerativen Erkrankungen. Krankengymnastisch unterstütztes Stand- und Gangtraining ist ein wesentlicher Bestandteil der Behandlung und kann die Gangsicherheit verbessern und Stürze verhindern. Die symptomatische medikamentöse Therapie ist unbefriedigend. Pathogenetisch sinnvolle Therapieansätze mit ermutigenden Resultaten in unkontrollierten Studien sind die Verstärkung der cholinergen Neurotransmission in Mittelhirn und Thalamus mit zentral wirksamen Cholinesterasehemmern und die Regularisierung der Purkinjezellfunktion im Kleinhirn mit Kaliumkanalblockern. Kerngebiete im Hirnstamm, die Zielregionen der tiefen Hirnstimulation sind (N. subthalamicus, N. pedunculopontinus), entsprechen wichtigen Zentren für die Gangsteuerung (subthalamisches und mesencephales Lokomotionszentrum). Entsprechend beeinflusst die Therapie die Stand- und Gangfähigkeit. Die aktuelle Studienlage zur symptomatischen Therapie von Gangstörungen im Alter wird zusammengefasst.

Abstract

Gait disorders are among the most common presenting symptoms in neurology. In the elderly, multiple causes of gait instability and dizziness may occur in the same subject. Relevant pathogenetic factors are sensory deficits (visual, vestibular, somatosensory), neurodegenerative processes (cortical, extrapyramidal, cerebellar), toxic factors (medication, alcohol) and anxiety (primary or as the result of falls). Reduced mobility reduces the quality of life; associated falls increase morbidity and mortality. The evaluation of aged people with the chief complaint “gait disorder” should focus on the identification of specific deficits. This is the prerequisite for reasoned therapy. Besides treatment of the underlying pathology there is a need for effective symptomatic therapy, in particular for degenerative disorders. Physical therapy with postural and locomotor training remains the basis of treatment; it can improve gait and prevent falls. So far, symptomatic drug treatment is unsatisfactory. Based on pathophysiology and uncontrolled studies, the most promising approaches are to support cholinergic neurotransmission in the midbrain and thalamus by central cholinesterase inhibitors and the regularisation of Purkinje cell function by potassium channel blockers. Brain stem nuclei which are target regions for deep brain stimulation (subthalamic and pedunculopontine nucleus) are known to be relevant for locomotor control (subthalamic and mesencephalic locomotor region). Accordingly, deep brain stimulation also affects posture and gait. The current literature on symptomatic therapy for gait disorders in the elderly is summarised.

Schlüsselwörter

Alter - Gangstörung - Lokomotion - Stürze

Key words

age - gait disorder - locomotion - falls
 

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