293
ORIGINAL ARTICLE
Dual-Task Complexity Affects Gait in People With Mild
Cognitive Impairment: The Interplay Between Gait
Variability, Dual Tasking, and Risk of Falls
Manuel Montero-Odasso, MD, PhD, Susan W. Muir, PhD, Mark Speechley, PhD
ABSTRACT. Montero-Odasso M, Muir SW, Speechley M.
Dual-task complexity affects gait in people with mild cognitive
impairment: the interplay between gait variability, dual tasking,
and risk of falls. Arch Phys Med Rehabil 2012;93:293-9.
Objective: To determine the effect of 2 different dual tasks on
gait variability in people with mild cognitive impairment
(MCI) compared with control subjects.
Design: Cross-sectional study.
Setting: Memory clinic at a university hospital.
Participants: Older adults with MCI (n43) and cognitively
normal control subjects (n25) from the community. Gait was
assessed under single (usual walking) and dual tasking (naming
animals and subtracting serial 7s), using an electronic walkway.
Interventions: Not applicable.
Main Outcome Measures: The dependent variable was the
coefficient of variation of gait variability, a marker of gait
stability and an established risk factor for falls. Two-way
repeated-measures analysis of variance was used to examine
main effects (group, task) and their interaction.
Results: A significant difference was found within and be-
tween groups (P.016) of increasing gait variability as dual-
task complexity increased. Gait velocity decreased within groups
as dual-task complexity increased. The magnitude of increased
gait variability across tasks was greater for the MCI group
(2.68% 9.84%) than for the control group (1.86%3.74%), show-
ing a significant between-group difference (P.041).
Conclusions: Dual-task load significantly increased gait vari-
ability in the MCI group compared with the control group, an
effect that was larger than the changes in gait velocity. The
magnitude of this impairment on gait stability was related to
the complexity of the dual task applied. Our findings help to
explain the high risk of falls recently described in older adults
with MCI, and may help in the identification of fall risk in
cognitively impaired persons.
Key Words: Gait; Rehabilitation; Cognition; Attention;
Aged.
2012 by the American Congress of Rehabilitation
Medicine
From the Department of Medicine, Division of Geriatric Medicine, Parkwood
Hospital, University of Western Ontario, London (Montero-Odasso, Muir); Gait and
Brain Lab, Lawson Health Research Institute, London (Montero-Odasso); and De-
partment of Epidemiology & Biostatistics, University of Western Ontario, London
(Speechley), ON, Canada.
Supported by operating grants from the Drummond Foundation, Montral, the
Physician Services Incorporated Foundation, Toronto and the Canadian Institutes of
Health Research.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Manuel Montero-Odasso, MD, PhD, Parkwood Hospital, Di-
vision of Geriatrics, 801 Commissioners Rd E, Room 280, London, Ontario, Canada
N6A 5A5, e-mail: mmontero@uwo.ca.
0003-9993/12/9302-00564$36.00/0
doi:10.1016/j.apmr.2011.08.026
F ALL RISK IS DOUBLED among older adults with cog-
nitive impairment, but the mechanisms of the increased fall
1,2
risk are not completely understood. Mild cognitive impair-
ment (MCI) is considered a transitional phase between normal
aging and dementia.3,4 People with MCI represent a highly
vulnerable population, as they face an elevated risk for con-
version to dementia. Interestingly, it has been recently de-
scribed that they are also at an increased risk for falls and
mobility decline.5,6
Walking has long been considered primarily an automatic
motor task, but an emerging body of evidence suggests that this
view is simplistic, and by contrast, cognitive function plays a
key role even in the regulation of routine walking.7-9 The
importance of this cognitive control is most easily demon-
strated in older people with memory problems and dementia.
Since the seminal stops walking while talking study,10 which
demonstrated that the inability to maintain a conversation while
walking is a marker for future falls, observing people walking
while they perform a secondary task, the dual-task paradigm,
has been used to assess the interaction between cognition, gait,
and the risk of falling. During dual tasking, the subject per-
forms an attention-demanding task while walking to assess for
any modifications, compared with the reference task, on either
the cognitive or the walking subtasks.11 The underlying hy-
pothesis is that 2 simultaneously performed tasks interfere and
compete for brain cortical resources.11,12-14 The change in an
individuals gait performance from a single task to a dual task
is known as the dual-task cost. The magnitude of these
dual-task costs reveals the insufficiency of the cortical control
to regulate walking and has been associated with an increased
fall risk.15,16 Dual tasking is also clinically relevant because
most activities of daily living involve the simultaneous perfor-
mance of 2 or more cognitive and motor tasks, making it
representative of real-life situations where falls are likely to
occur.9
Gait is a complex motor behavior with many measurable
facets beside gait velocity,17 and with the advent of equipment
to precisely measure several quantitative aspects of walking,
the variability of the stride time is a growing research field that
provides an interesting window for the study of the cognitive
control of gait and risk of falls.18 For instance, low stride-to-
stride variability reflects automatic processes that require min-
List of Abbreviations
a-MCI amnestic mild cognitive impairment
ANOVA analysis of variance
CDR Clinical Dementia Rating Scale
CoV coefficient of variation
MCI mild cognitive impairment
na-MCI nonamnestic mild cognitive impairment
MMSE Mini-Mental State Examination
MoCA Montreal Cognitive Assessment
Arch Phys Med Rehabil Vol 93, February 2012
294 DUAL-TASK COMPLEXITY ON GAIT IN MILD COGNITIVE IMPAIRMENT, Montero-Odasso
imal attention and is associated with efficient gait control and
gait safety.19 By contrast, high stride time variability has been
associated with executive and attentional deficits, Parkinsons
disease, and Alzheimers disease.20-23 Additionally, high stride
time variability has been shown to predict future falls in com-
munity-dwelling older persons even when gait velocity failed
to distinguish between those who fell and those who had not.24
Gait variability characteristics and how these are affected by
dual-task challenges have not been evaluated in older adults
with MCI. Therefore, the aim of this study was to characterize
the effect of 2 different dual-task challenges on gait variability
and to determine whether an increase in the secondary task
complexity would yield a predictable cost in gait performance
in people with MCI. We tested the following hypotheses: (1)
gait performance is affected more by dual-task challenges in
people with MCI than in cognitively normal control subjects;
(2) a worsening gait performance in people with MCI (ie,
decreased gait velocity and increased gait variability) will be
greater while doing more complex mental task such as sub-
tracting serials 7s, than when simply naming words; and (3) the
increase in gait variability is greater than the reduction in gait
velocity.
METHODS
Study Participants
A convenience sample of participants with MCI and cogni-
tively normal control subjects were recruited. Participants with
newly diagnosed MCI were recruited from the Aging Brain
and Memory Clinic at Parkwood Hospital. The identification
of MCI was based on the most recent consensus criteria4 that
included the presence of subjective memory complaints from
the patient and family, objective memory impairment (assessed
using the Mini-Mental State Examination [MMSE] and Mon-
treal Cognitive Assessment [MoCA]), preserved general intel-
lectual function (assessed clinically), absence of significant
functional impairment, and absence of clinical dementia.4 Ad-
ditionally, participants needed to score 0.5 on the Clinical
Dementia Rating Scale (CDR). Controls were recruited by
newspaper advertisement and from a community-based fitness
program for older adults.
Inclusion criteria for the MCI group were a recent diagnosis
of MCI, aged 65 years and older, and able to walk indepen-
dently without a gait aid (eg, cane or walker). In the control
group, inclusion criteria were aged 65 years and older, an
absence of subjective cognitive complaints, normal objective
cognitive testing, absence of functional impairment, and able to
walk independently without a gait aid. Exclusion criteria for
both groups included the inability to understand English, par-
kinsonism or any neurologic disorder with residual motor def-
icits (eg, stroke, epilepsy), musculoskeletal disorders or a his-
tory of knee or hip replacement surgery that affected gait
performance, use of psychotropic medications that affected
motor performance (eg, neuroleptics, benzodiazepines), or ac-
tive major depression. During assessment, a formal clinical
examination was done to evaluate the effect of diseases and
comorbidities that might affect gait performance. The project
was approved by the University of Western Ontario Health
Sciences Research Ethics Board, and all participants provided
informed consent.
Medical and Cognitive Assessments
Sociodemographic characteristics, comorbidities, a history
of falls in the past 6 months, fear of falling, self-reported
physical activity level, functionality on activities of daily liv-
Arch Phys Med Rehabil Vol 93, February 2012
ing, and medications were recorded. Basic and instrumental
activities of daily living were evaluated using the Lawton-
Brody25 scale, to ensure absence of functional impairment.
Objective cognitive status of all participants was assessed using
the MMSE (score, 0 30)26 and the MoCA (score, 0 30; higher
score indicating better performance).27,28 A CDR was per-
formed in all participants with MCI. Objective cognitive im-
pairment in our MCI participants was operationalized as a
normal MMSE score (26) combined with a low MoCA score
(26); this pattern has been previously validated for MCI
identification.27,29 Finally, we subcategorized our participants
with MCI as amnestic MCI (a-MCI) and nonamnestic MCI
(na-MCI) by using a simple and valid approach29 for descrip-
tive purposes only.
Quantitative Gait Assessment
Gait performance under single- and dual-task challenges was
assessed using an electronic walkway system (GAITRite Sys-
tema) that is 600cm in length and 64cm in width. As partici-
pants walk along the mat, imbedded sensors are activated by
the pressure of their feet and deactivated when the pressure is
released. A computer processed the footsteps, providing data
for both spatial and temporal parameters. Start and end points
were marked on the floor with tape 1m from either end of the
mat to avoid the recording of acceleration and deceleration
phases. Participants performed 1 practice trial walking on the
mat to familiarize themselves with the protocol. Gait velocity
(cm/s), stride time (ms), and stride time variability (percentage
of coefficient of variation [%CoV]), the principal gait measures
of interest, were measured during the single-task and dual-task
trials. The single-task trial consisted of walking the length of
the mat at a self-selected usual pace. For the dual-task trials,
participants walked the length of the mat while subtracting
serial 7s from 100 aloud or while naming animals aloud. These
2 different dual-task conditions were selected based on previ-
ous research which demonstrated that subtractions depend
more on working memory and attention, while naming animals
out loud is more related to verbal fluency, which relies on
semantic memory.30,31
To balance and minimize the effects of learning and fatigue,
the order of the single and dual tasks was randomized. While
performing the dual-task trials, there was no instruction to
prioritize the gait or cognitive task. Allowing both gait and
cognitive tasks to vary has previously been shown to provide a
more natural representation of daily living activities of older
individuals.8,32 Reliability has been previously established by
our group for the use of this gait assessment protocol in people
with MCI.33
Data Analysis
Demographic and medical characteristics were summarized
using either means and SDs, or frequencies and percentages, as
appropriate. Comparisons between groups were made using
unpaired t tests or Mann-Whitney tests as deemed appropriate,
with adjustment made for multiple comparisons using the Bon-
ferroni correction. The CoV for stride time was used to quan-
tify gait variability under each testing condition. The CoV was
calculated as follows:
SDst
COVst 100
meanst
where CoVst is the CoV of stride time, SDst is the SD of stride
time, and meanst is the mean stride time.
 DUAL-TASK COMPLEXITY ON GAIT IN MILD COGNITIVE IMPAIRMENT, Montero-Odasso 295

A 2-way repeated-measures analysis of variance (ANOVA)
was performed to evaluate the effect of cognitive status (group)
across the increasing complexity of gait tasks (condition) and
their interaction (group condition). If the overall F test was
significant, post hoc testing was performed (Tukey procedure)
to identify which pair-wise comparisons between and within
groups were significantly different from one another. A sensi-
tivity analysis of the ANOVA analysis adjusted for age and
history of falls was performed. The level of statistical signifi-
cance was set at P.05 (2-sided), and the statistical analyses
were conducted using SAS software version 8.2.b
RESULTS
Forty-eight people with a diagnosis of MCI were eligible for
this study, and 43 met the study inclusion criteria. Five people
with an MCI diagnosis were excluded for the following rea-
sons: MoCA greater than 26 (n3), MMSE less than 26 (n1),
and English language difficulties (n1). Twenty-nine people
were assessed for the cognitively normal group, and 25 people
met the study inclusion criteria, with 4 people excluded for age
less than 65 years (n1), MMSE less than 26 (n1), and
MoCA less than 26 (n2). All participants were fully func-
tional in their basic and instrumental activities of daily living.
Demographic and clinical characteristics are presented in table
1. As expected, the MCI group differed from the control group
on cognitive status. The MCI group was also older, more often
had a positive fall history, and was more likely to be sedentary.
The level of physical activity and age was highly correlated.
Among the MCI group, 31 (72%) met the criteria for a-MCI, 11
(26%) for na-MCI, and 1 participant did not have data available
to allow group assignment.
Results from the repeated-measures ANOVA are presented
in table 2. Statistically significant differences in the mean
values were found within each cognitive group across the
different walking test conditions for gait velocity (P.0001),
stride time (P.0008), and gait variability (P.0013). Differ-
ences in the mean values between groups on each walking test
condition were also found for gait velocity (P.0001), stride
time (P.0001), and gait variability (P.0001). The magni-
tude of increased gait variability across tasks was greater for
the MCI (2.68%9.84%) than the control group (1.86%
3.74%), showing a between-group significant difference
(P.041). The test for interaction between cognitive status and
the walking test condition for gait velocity was not statistically
significant (P.23) (fig 1). A statistically significant interaction
effect was found, though, between cognitive status and walking
test condition in favor of the MCI group for gait variability,
demonstrating that gait variability increased as complexity of
the gait task increased (fig 2). A sensitivity analysis to evaluate
the robustness of the main analyses was performed, adjusting
for age and history of falls; the directions and magnitude of
associations (a difference 10%) of the results were main-
tained. Figure 3A demonstrates the nonsignificant interaction
effect of dual tasking on gait velocity; in contrast, this effect
was evident and significant on gait variability (fig 3B). Finally,
the effect of a complex dual-task challenge (serial 7s subtrac-
tion) on gait variability can be seen in figure 4 when comparing
variability in stride time between a control participant and a
participant with MCI.
DISCUSSION
This study has demonstrated that gait performance differs
between people with MCI and people with normal cognition,
particularly under dual tasking. Both groups showed a decrease
in gait velocity and an increase in gait variability with the
different dual-task challenges. However, the effect of the dual-
task load on the regulation of stride-to-stride time, assessed as
gait variability, was significantly greater in those with MCI.
This effect on gait variability was much larger than the effect
seen on gait velocity.
The dual-task cost for gait velocity found in our study is
consistent with previous research among patient populations

Table 1: Demographic and Clinical Characteristics of Study Participants Stratified by Cognitive Status Group
Variable Controls (n25) MCI (n43) P

Age (y) 71.54.1 75.16.3 .013*

MMSE 29.50.6 27.81.6 .0001*
MoCA 28.21.5 23.02.3 .0001*
Sex (female) 22 (88) 23 (54) .012*
Body mass index (kg/m2) 26.84.1 25.83.8 .31
Had fall in past 6 months 5 (20) 23 (54) .01*
Fear of falling 5 (20) 11 (26) .77
Years of education 13.03.2 12.73.3 .72
No. of current medications 4.13.4 5.83.6 .24
Comorbidities
Hypertension 9 (36) 24 (56) .14
Diabetes 2 (8) 4 (9) 1.00
Stroke or transient ischemic attack 0 (0) 4 (9) .29
Parkinsons disease 0 (0) 1 (2) 1.00
Lung disease 1 (4) 4 (9) .64
Myocardial infarction 0 (0) 6 (15) .08
Congestive heart failure 0 (0) 2 (5) .52
Level of physical activity
Vigorous 17 (68) 15 (35) .0046*
Moderate 8 (32) 17 (40)
Sedentary 0 (0) 10 (23)

NOTE. Values are mean SD, n (%), or as otherwise indicated.

*Testing between groups was conducted using the Bonferroni correction for multiple comparisons to maintain statistically significant
difference at P.05.

Only data from 42 MCI subjects were available to calculate current number of prescription medications.

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296 DUAL-TASK COMPLEXITY ON GAIT IN MILD COGNITIVE IMPAIRMENT, Montero-Odasso

Table 2: Results of 2-Way ANOVA on Gait Parameters by Cognitive Status Group and Walking Test Condition
Walking Test Condition

Repeated-Measures 2-Way
Gait Variable Group Usual Gait Naming Animals Serial 7s ANOVA* (P)

Gait Velocity (cm/s) Control (n25) 134.0021.70 115.8829.26 106.2528.43 Group .0001
MCI (n43) 110.9820.67 89.2625.25 74.7924.40 Condition .0001
Interaction .23

Stride time (ms) Control (n25) 1035.7466.54 1153.42144.77 1219.04230.54 Group .0008
MCI (n43) 1120.8894.72 1390.11361.56 1649.70658.40 Condition .0001
Interaction .0165

Gait variability (% CoV) Control (n24) 1.860.66 3.592.95 3.743.31 Group .0013
MCI (n43) 2.681.31 7.167.76 9.8410.13 Condition .0001
Interaction .0419

NOTE. Values are mean SD or as otherwise indicated.

Abbreviation: % CoV, percent coefficient of variation in stride time.
*P value reported for Main Effect of Group, Condition, and the interaction of Group x Condition with statistical significance set at P.05.

with MCI and Alzheimers disease2,34,35; however, this is 1 of
the first studies to assess and compare the effect of 2 different
types of dual tasks and to assess their effect on gait variability
in people with MCI.
Previously, it has been demonstrated that motor dysfunction
is present in older adults who will eventually develop cognitive
decline and dementia.36-38 This motor dysfunction, evaluated
as gait velocity, may have its onset up to 12 years before MCI
conversion.36 Therefore, the presence of a slower gait in our
MCI group is consistent with these findings. Interestingly, both
groups in our study had a normal gait velocity (1m/s) under
the single-task test condition. However, and in line with our
first hypothesis, the type of dual task applied showed a differ-
ential effect on the gait performance, principally in the MCI
group. A more complex cognitive task with a profound cortical
demand, such as subtracting serial 7s from 100, produced a
greater dual-task detrimental effect on gait performance when
compared with a less demanding task such as naming animals,
as shown in figure 3. The significant and graded decline on gait
velocity while engaging in a more demanding dual-task chal-
lenge in our study is in agreement with a previous study39,40 of
physically frail older adults. In the same vein, the present
findings are consistent with a recent study41 evaluating the
effect of different types of dual-task challenges in healthy older
adults. In that study, 2 different types of dual tasks, phoneme
monitoring and serial subtractions, had different effects on gait
performance. The authors postulated that these 2 types of dual
tasks might tax distinct cognitive resources since the nature of
the dual task also differs: attentional demands of phoneme
monitoring are essentially uniform over time, when compared
with the increased attention needed while doing serial subtrac-
tions.
In the present study, gait variability was differentially
affected by the type of dual task performed, more signifi-
cantly in people with MCI (see fig 3), demonstrating that
this gait-derived parameter is a very sensitive quantitative
measure of the concurrent task. These results underscore the
observation that the effects on gait are related to the nature

Fig 2. Mean gait variability in older adults with MCI (n43) and
Fig 1. Mean gait velocity, with SDs, in participants with MCI (n43) normal cognition (n25) while performing a usual walking task and
and normal cognition (n25) while performing a usual walking task 2 dual-task walking conditions. Abbreviation: % CoV, percent coef-
and 2 dual-task walking conditions. ficient of variation in stride time.

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 DUAL-TASK COMPLEXITY ON GAIT IN MILD COGNITIVE IMPAIRMENT, Montero-Odasso 297

Fig 3. Interaction between cognitive status and 3 different walking conditions for gait velocity (A) and gait variability (B). Abbreviation: %
CoV, percent coefficient of variation in stride time.

of the dual task, the aspect of the gait under study, and the
cognitive reserve of the subject.
Our findings have novel research and clinical implications.
From a research perspective, we found that gait variability is
more sensitive to dual-tasking load than gait velocity, which
may help to refine the measures used in future research studies
for fall risk in cognitively impaired populations. Additionally,
we showed that the type of dual tasking with different cognitive
loads might generate differential decrements in gait perfor-
mance. This is particularly important for the comparison of
results across studies, as different tasks have the potential to
identify different populations of at-risk individuals.
A potential clinical implication of our findings relates to the
identification of possible fall risk and mobility dysfunction in
people with MCI. Gait variability is an established marker of
fall risk, and it has been prospectively proven to predict falls

Fig 4. Effect of complex dual-task load (serials subtractions by 7s) in stride time in a participant with normal cognition (A) compared with
a participant with MCI (B).

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298 DUAL-TASK COMPLEXITY ON GAIT IN MILD COGNITIVE IMPAIRMENT, Montero-Odasso
even when gait velocity failed to identify fallers in community-
dwelling older adults. Additionally, the recent advent of por-
table gait mats allows for easy quantification for gait variability
in clinical settings, facilitating fall risk identification in older
people who have an otherwise unremarkable gait performance.
Recent recommendations concerning fall prevention and inter-
ventions to decrease falls among cognitively impaired older
adults advocate to screen/test people with MCI according to the
evidence available for cognitively intact, community-dwelling
older adults.42 However, we have found that changes in gait
behavior under dual tasking are a clear marker of fall risk in
older adults with MCI. This suggests that people with MCI,
when they are exposed to a cognitive challenge while walking,
have an increased risk of falls. Interestingly, gait velocity under
single-task condition was within normal limits in both groups
(1m/s), and only dual-task testing revealed abnormal slow-
ing (1 m/s) and gait instability (high variability) in the MCI
group. Therefore, dual-task assessment may be a more sensi-
tive measure of gait impairment than single-task assessment,
thereby providing a means to identify cognitively impaired
persons at risk of falls. A future prospective study is needed to
test this hypothesis.
Study Limitations
Some limitations of this study should be noted. In the data
analysis, we were not able to adjust for all potential confound-
ers that may affect gait and cognition; however, our findings
were maintained after controlling for age and a history of falls.
The limited sample size precluded our ability to further explore
associations between MCI subtypes or impairment in specific
cognitive domains, such as executive and attentional function,
with the use of the dual-task cost approach.43 These limitations
do not detract or alter the importance of our findings, which
showed a differential effect of dual-task challenges in gait
variability in people with MCI when compared with cogni-
tively normal older adults.
CONCLUSIONS
Dual-task load impairs and increases gait variability in peo-
ple with MCI, an effect that was larger than the effect seen on
gait velocity. These findings also suggest that cognitive control
of gait is differentially challenged by the complexity of dual-
task load. Older people with MCI had an impaired ability to
regulate and minimize gait variability while performing dual-
task challenges, and the magnitude of this impairment is related
to the kind and complexity of the dual task performed. Our
findings may explain the high risk of falls recently described in
this population, and suggest that their fall risk should not be
assessed using methodology established among cognitively
normal older adults.
Acknowledgments: We thank Maggie Hall for her help in the
participants assessment and data gathering, and Kevin Hansen for his
help in the manuscript preparation.
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Arch Phys Med Rehabil Vol 93, February 2012