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Syncope in the Elderly Syncope in the Elderly ––
Assessment and TreatmentAssessment and Treatment
Professor Rose Anne Kenny
Trinity College Dublin
Newcastle University
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DefinitionDefinition
Syncope is a syndrome consisting of a Syncope is a syndrome consisting of a
relatively relatively short periodshort period of of temporarytemporary
and and self limitedself limited loss of consciousnessloss of consciousnesscaused by transient reduction in blood flow to the
brain (most often the result of systemic
hypotension).
• Transient
• Spontaneous recovery
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EpidemiologyEpidemiology
15% <18y
25% 17-26y military
16% m
19% f 40-59y
23% nursing home (underestimate?)
Highest with cardiovascular comorbidity, in nursing populations
ER 1-3%
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EpidemiologyEpidemiology
IncidenceIncidence
• Adults: 6.2 per 1000 person years
• 70-79 : 11 per 1000 person years
• > 80 19 per 1000 person years
Soteriades NEJM 2002
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Syncope in the ElderlySyncope in the Elderly
Why more common in Ageing?Why more common in Ageing?
• Age related physiology
• Comorbidity
• Medications
• Age related pathology- cardiac and neurodegeneration
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ClassificationClassification
• Neurally mediated
• Orthostatic
• Cardiac Arrhythmia
• Structural Heart Disease
• Cerebrovascular
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ClassificationClassification
NeurallyNeurally MediatedMediated• Vasovagal Syncope
• Carotid sinus Syncope
• Situational FaintAcute haemorrhage
Cough, sneeze,
Gastrointestinal stimulation
Micturition
Post exercise
Other (brass instrument play, weight lifting, postprandial)
• Glossopharyngeal and trigeminal neuralgia
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ClassificationClassification
OrthostaticOrthostatic
• Primary Autonomic failure syndromes (PAF, MSA, PD, ? POTS)
• Secondary Autonomic failure
(DM, drugs, Alcohol Amyloid)
• Volume depletion
(Haemorrhage, diarrhoea, Addison's, ?Age)
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ClassificationClassification
Cardiac Arrhythmias as primary causeCardiac Arrhythmias as primary cause
• SND
• AV Conduction
• PSVT, VT
• Inherited Syndromes (Long QT, Brugada)
• Implanted device malfunction
• Drug Induced Arrhythmia
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ClassificationClassification
Structural Cardiac/CardiopulmonaryStructural Cardiac/Cardiopulmonary• Cardiac Valvular
• Acute MI
• Obstructive cardiomyopathy
• Atrial Myxoma
• Acute Aortic dissection
• Pericardial
• Pulmonary Embolus/ Hypertension
CerebrovascularCerebrovascular• Vascular Steal Syndromes
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Syncope in the ElderlySyncope in the Elderly
Causes >65Causes >65Secondary syncope facility- open access ER and GPs
OH – 30%
VVS- 30%
CSH- 20%
Arrhythmia-20%
More than one possible attributable causeMore than one possible attributable cause 1/31/3
Alcock OShea 98
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Cardiovascular AssessmentCardiovascular Assessment
methodsmethods
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Number of Investigations before dx
in ‘Syncope’Investigations Diagnosis AchievedInvestigations Diagnosis Achieved
• History and examination 1.6• Holter monitoring 9.8• R Test 2.6
•• CT brain 87CT brain 87• Laboratory tests 118• ECG 73• Echo 64• Head up tilt 2.6• Chest x-ray not dx• Coronary Angio not dx• EP studies not dx
•• EEG not EEG not dxdx
•• Carotid Carotid DopplersDopplers not not dxdx
Farewell Heart 05
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Syncope/Falls/DizzinessSyncope/Falls/Dizziness
History, physical examination, ECG, SBP supine and upright,
carotid sinus massage, blood chemistry and haematologyInitial evaluation
Diagnostic
Treatment
Inconclusive
Cerebrovascular Psychiatric
Suggestive
Cardiac Neurally-mediated
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Syncope/Unexplained fallsSyncope/Unexplained falls (?)
History, physical examination, ECG, SBP supine and upright,
carotid sinus massage, blood chemistry and haematologyInitial evaluation
Diagnostic
Treatment
InconclusiveSuggestive
Cardiac
2°stepEcho - Holter,
Stress test? Lung scan?
3°step EP study
4°step CSM - Tilt test - ATP test
Consider other causes
5°step Loop ECG
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Syncope/Unexplained fallsSyncope/Unexplained falls (?)
History, physical examination, ECG, SBP supine and upright,
carotid sinus massage, blood chemistry and haematologyInitial evaluation
Diagnostic
Treatment
InconclusiveSuggestive
Cardiac Neurally-mediated
CSM - Tilt test - ATP test
Echo - Holter
EP study
(if heart disease)
Consider other causes
Infrequent Frequent
Loop ECGStop
work-up
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Psychiatric evaluation
EEG - CT scan - MRI scan
Doppler ultrasonography
Consider other causes
Syncope/Unexplained fallsSyncope/Unexplained falls (?)
History, physical examination, ECG, SBP supine and upright,
carotid sinus massage, blood chemistry and haematologyInitial evaluation
Diagnostic
Treatment
Inconclusive
Cerebrovascular Psychiatric
Suggestive
Cardiac Neurally-mediated
CSM - Tilt test - ATP test
Echo - Holter
2°stepEcho - Holter,
Stress test? Lung scan?
3°step EP study
4°step CSM - Tilt test - ATP test
Consider other causes
5°step Loop ECG
CSM - Tilt test - ATP test
Echo - Holter
EP study
(if heart disease)
Consider other causes
Infrequent Frequent
Loop ECGStop
work-up
Consider other causes
Infrequent Frequent
Loop ECGStop
work-up
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Transient Loss of Transient Loss of
ConsciousnessConsciousness
TLOC
TraumaConcussion
May not be transientNo trauma
Intoxication
Metabolic
Subarachnoid
Epilepsy
TLOC
No trauma
SyncopeEpilepsySteal
Psychogenic
Cataplexy
Drop Attacks
UnconsciousnessApparent
Unconsciousness
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Syncope Syncope vsvs EpilepsyEpilepsy
12% ‘tonic clonic like movements’
80% myoclonic (Lempert’s video)
• Brief
• After LOC
• Less coarse
• Not tonic clonic (gross flailing, random, contraction of axial muscles different to regular contractions of
epilepsy)
• Video- Mobile phone
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Syncope Syncope vsvs TIATIA
• TIA does not cause syncope
• Vertebral Ischemia - rare- neurology
• Transient cerebral disturbances should not be
included in the differential for Syncope
• Unnecessary Investigations
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Syncope and Syncope and Falls Falls in the Elderlyin the Elderly
Atypical presentations syncopeAtypical presentations syncope
‘‘Syncope presenting as fallsSyncope presenting as falls’’
70% events > 70yrs unwitnessed,
No collateral history
McIntosh 99
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Syncope and Falls in the ElderlySyncope and Falls in the Elderly
After 50 yrs
3% per year loss muscle strength
7070-- 74 yrs74 yrs (Kings College London, 2002)
• 50% women, 15% men mount 30 cm step• 80% women, 30% men 3 miles/hr 20min
Leads unstable gait and balance
Transient arrhythmias/low BPTransient arrhythmias/low BP…….falls .falls
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Falls / SyncopeFalls / Syncope
Overlap
SyncopeSyncope amnesia
unwitnessed
Falls Falls gait/balance instability
and acute hypotension
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Accident and Emergency
Syncope / Fall 34%(n = 24,237)
Non-Fallers 59%
71, 000 >50 years
Richardson Pace 1999Richardson Bond JACC 2001
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Syncope/ Fall 45% (n=4793)
Accident and Emergency
> 65 yrs
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Accident and Emergency
Cognitively Impaired Cognitively Impaired
25%25%
AccidentalAccidental
35%35%
Medical Diagnosis
22%22% Drop Attacks 18%Drop Attacks 18%
Richardson PACE 1999, Age Ageing 2001
Davies Age Ageing 1999, Parry JAGS 2005
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Risk Factors in Recurrent Accidental Falls
0
10
20
30
40
50
60
70
80
90
100
% with risk
factor
Balance
Gait
Home Hazards
Vasovagal
Medication
Davidson Age Ageing 05
CSH
OH
Arrhythmia
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Recurrent Accidental FallsRecurrent Accidental Falls (n=386)
RCT (one year)
Intervention Control
340 falls340 falls 1320 falls1320 falls
Davidson Age Ageing 05
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Accident and Emergency
Cognitively Impaired Cognitively Impaired
25%25%
AccidentalAccidental
35%35%
Medical Diagnosis
22%22% Drop Attacks 18%Drop Attacks 18%
Richardson Kenny PACE 1999, Age Ageing 2001
Davies Kenny Age Ageing 1999, Parry Kenny JAGS 2005
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Risk factor
Risk Factors in Cognitively Impaired Fallers
0
20
40
60
80
100 Balance/gait
NeurocardNeurocard / Arrhythmia/ Arrhythmia
Environment
Medication
Feet/footwear
VisionMedical
Depression
% o
f p
atie
nts
with
each
ris
k fa
cto
r
Other
Shaw BMJ 2002
Intervention Intervention -- NSNS
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Newcastle Accident and Emergency StudyNewcastle Accident and Emergency Study
Drop Attacks 18%Drop Attacks 18%
‘‘no effective no effective txtx’’
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0%
10%
20%
30%
40%
50%
60%
70%
50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 85 - 89 90 - 94
Age Group
Percentage
80 - 84
VDCSH
CICSH
n = 122
n = 9
n = 76
n = 124
n = 130
n = 130
n = 157n = 183
n = 179
1 in 4 CICSH
Drop Attacks
Richardson Bexton Kenny PACE 1998
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What are the interventionsWhat are the interventions
• Conservative Advise- avoid provoking situations, increase fluid intake, exercise
• Stop or Reduce medications (cardiovascular/psychotropic)
• Give medications-
low BP (Midodrine, fludrocortisone), antiarrhythmics
• Pacemaker
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Syncope Cardiovascular interventions for Falls Syncope Cardiovascular interventions for Falls
Intervention trials for fallsIntervention trials for falls
Positive trial
no cognitive impairment
• Multifactorial (Close 1999, Davison& Kenny 2004)
• Single CICSH (SAFEPACE1 2001)
No Evidence
Cognitive Impairment or dementia
• Multifactorial (Shaw&Kenny BMJ 2002)
• Single CICSH (SAFEPACE2 subm)
Early InterventionEarly Intervention
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Infrastructure for Best Practice Infrastructure for Best Practice -- SyncopeSyncope
• Evaluation is haphazard and unstratified
• Specialties- cardiology, neurology, geriatric, emergency medicine
• Variation – diagnostic tests
attributable diagnoses
% unexplained syncope
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SyncopeSyncope
Italian Series: (older patients)
28 hospitals
Tests
Carotid sinus massage 0 - 58%
Tilt 0 - 50%
Diagnoses
Neurally mediated Syncope 10 - 79%
Pacing Carotid Sinus Syndrome 1 - 25%
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Infrastructure for Best Practice Infrastructure for Best Practice -- SyncopeSyncope
• If models of care unchanged diagnosis and treatment will remain inadequate
• Implementation guidelines inadequate
European Society Cardiology Guidelines on Syncope 2001, 2005
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Infrastructure for Best Practice
• Newcastle Model
• Rapid Access
• ‘One Site One Stop’
• Education/Communication Stakeholders
•• --6005 bed days6005 bed days at variance with peer hospital (2001)
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Sites NumberEpisodes
%Emergency
%Elective
AverageLoS (days)
13 1249 99 0.5 5
NCL 1105 37 62 2
8 1099 97 3 17
Savings Site 8 Savings Site 8
££3million3million
Performance / Activity Newcastle
1991
Length of stay 10 vs 2 days
zero vs 62% elective activity
saving 31 acute beds in yearKenny Age Ageing 02
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Setting up a falls and syncope Setting up a falls and syncope
serviceservice
SourcesSources of referral- capture at risk
• A&E, direct GP, in patients, out patient
LocationLocation Unit
• A&E, Cardiology
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Setting up a falls and syncope Setting up a falls and syncope
serviceservice
Management loadManagement load
Nurse practitioners, Multidisciplinary, Triage
Cardiology Team
Neurology Team Geriatric Med Team
Psychiatry/PsychologyPsychiatry/PsychologyENTENT
A&EA&E GPGP
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Setting up a falls and syncope Setting up a falls and syncope
serviceservice
Equipment- laboratory, ambulatory
Neurally mediated
Cardiac
Gait/Balance
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SummarySummary
A multidisciplinary rapid access
syncope /falls day case facility
improves quality of care by facilitating
application of guidelines, and reduces hospital costs by minimising number of acute hospital
admissions and length of stay.