Cortical Function, Postural Control, and Gait
Executive Functions Are Associated With Gait and
Balance in Community-Living Elderly People
Marianne B. van Iersel,1Roy P. C. Kessels,1,2,5Bastiaan R. Bloem,3
Andre ´ L. M. Verbeek,4and Marcel G. M. Olde Rikkert1
Departments of1Geriatrics,2Medical Psychology,3Neurology, and4Epidemiology and
Biostatistics, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
5Nijmegen Institute for Cognition and Information, Radboud University
Nijmegen, the Netherlands.
Background. Cognition influences gait and balance in elderly people. Executive functions seem to play a key role in
this mechanism. Previous studies used only a single test to probe executive functions, and outcome measures were
restricted to gait variables. We extend this prior work by examining the association between two different executive
functions and measures of both gait and balance, with and without two different cognitive dual tasks.
Methods. This is a cross-sectional study with randomly selected community-living elderly people. Executive functions
were tested with the Trail Making Test Parts A and B and the Stroop Color Word Test; memory with Cambridge
Neuropsychological Test Automated Battery (CANTAB) subtests. Patients walked without and with two dual tasks
(subtracting serial sevens and animal naming). Main outcomes focused on gait (velocity, stride length, and stride time
variability), measured on an electronic walkway, and balance, measured as trunk movements during walking. Associations
were assessed with multiple regression models.
Results. One hundred elderly people, with a mean age 80.6 years (range 75–93 years) participated. Both dual tasks
decreased gait velocity and increased variability and trunk sway. Executive functions were associated with only stride
length variability and mediolateral trunk sway during performance of animal naming as the dual task. Memory was not
associated with the gait and balance variables.
Conclusions. In community-living elderly people, executive functions are associated with gait and balance impairment
during a challenging dual-task condition that also depends on executive integrity. Next steps will be to explore the value of
executive functions in defining fall-risk profiles and in fall-prevention interventions for frail patients.
Key Words: Gait—Balance—Executive functions—Memory—Elderly people.
functions. However, it is becoming increasingly clear that
walking is in fact tightly linked to cognitive functioning,
and this interplay takes place at several levels (1). First, both
gait impairment and cognitive problems are common with
aging, and they frequently coincide in elderly people.
Second, gait and cognitive problems both have a great
impact on quality of life and everyday functioning of older
people and their caregivers. In the last decade, evidence has
also emerged for an actual pathophysiological interaction
between gait and cognition. Having a gait disorder increases
the chances of developing non-Alzheimer dementia by
threefold (2). Conversely, people with dementia more often
have gait disorders and also sustain an increased risk of
falling (3,4). This interdependence between cognition with
gait and balance can also be found in healthy older people
(5). Dual tasks are one method of investigating the effect
of cognition on gait and balance control (5). Dual tasks
may result in a suboptimal performance in gait, cognition, or
both, because attention has to be divided or because of
ALKING is traditionally seen as an automatic motor
task that requires little, if any, higher mental
structural inference in neural networks of the frontal and
motor cortex (5,6). Another explanation is that the demands
of cognition and gait go beyond the limited central
A key cognitive factor in gait and balance control seems to
be executive functioning. Executive functions are defined as
a set of cognitive skills that are necessary to plan, monitor,
and execute a sequence of goal-directed complex actions (7).
Older people with poor executive functioning walk slower,
have increased stride variability, fall more often, and have
poorer performance on complex mobility tasks (8,9). These
previous studies clearly show that executive functions play
an important role in gait control. In the present study, we
aimed to extend this prior work in three ways. First, previous
studies probed executive functions with only a single test. In
contrast, we aimed to use a more extensive cognitive test
battery, including two different executive functioning tests
and two memory tests. These memory tests were included
because memory decline in old age is highly prevalent, and
there has been little study of the effects of memory
impairment on gait (8–12). We also included two different
Journal of Gerontology: MEDICAL SCIENCES
2008, Vol. 63A, No. 12, 1344–1349
Copyright 2008 by The Gerontological Society of America
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Received February 3, 2007
Accepted September 24, 2007
Decision Editor: Luigi Ferrucci, MD, PhD
EXECUTIVE FUNCTION, GAIT, AND BALANCE