people are living longer
DESCRIPTION
A multidisciplinary approach to identifying syncope in the elderly Professor Rose Anne Kenny St James Teaching Hospital and Trinity College Dublin. People are living longer. For most of humanity 3-4% > 65yrs 100 years ago ………. Better Health Care Better Awareness Less Stressful - PowerPoint PPT PresentationTRANSCRIPT
A A multidisciplinarmultidisciplinary approach to y approach to
identifying identifying syncope in the syncope in the
elderlyelderlyProfessor Rose Anne Professor Rose Anne
KennyKenny St James Teaching St James Teaching Hospital and Trinity Hospital and Trinity
College DublinCollege Dublin
People are living People are living longerlonger
For most of humanity 3-4% > 65yrs100 100 years ago ……….
Female life expectancy in the record-holding
country from 1840 to the present
50% females born today 50% females born today Live to 100yrs or beyondLive to 100yrs or beyond
Better Health CareBetter AwarenessLess StressfulBetter Environments
3 mths per year3 mths per year5 hours per day5 hours per day
DefinitionDefinitionSyncope is a syndrome Syncope is a syndrome
consisting of a relatively consisting of a relatively short short periodperiod of of temporarytemporary and and self self limitedlimited loss of consciousness loss of consciousness
caused by transient reduction in blood flow to the brain (most often the result of systemic hypotension).
Transient
Spontaneous recovery
Falls & Syncope are Falls & Syncope are CommonCommon
& Consequences are & Consequences are importantimportant
Reasons for Reasons for ERER attendance > attendance >7575 yr (UK, Italian) yr (UK, Italian)
21% general decline21% general decline
15% SOB15% SOB
15% 15% FallsFalls
13% Abdo Pain13% Abdo Pain
9% Chest Pain9% Chest Pain
7% Syncope5% Stroke5% Stroke
More common than More common than Stroke or Chest PainStroke or Chest Pain - and - and taken together - the commonest presentation taken together - the commonest presentation
Epidemiology Epidemiology SyncopeSyncope
15% < 18y
25% 17-26y military
16% m
19% f
2323% nursing homenursing home
per 1000 person years
Adults: 6.2
70-79 : 11
> 80 1919
40-59y
Soteriades NEJM 2002
ECS Eur Ht J 2004
Weiling 02
ERER
Syncope and collapse R55 ICD 10 Data England
Syncope and collapse R55 ICD 10 Data England
Epilepsy Hospital ActivityEpilepsy Hospital Activity
Causes- more common Causes- more common advancing ageadvancing age
Neurally mediated
Orthostatic
Cardiac Arrhythmia
Structural
Cerebrovascular
MedicationsMedicationsDehydrationDehydrationPhysiologicalPhysiological changes (Neurohumoral, Renal)Locomotor Locomotor (gait, balance, joint)
30% > 70s > one possible attributable
30% > 70s > one possible attributable
causecause
CausesCauses
Comorbid/TriggersComorbid/Triggers
SyncopeSyncope
Syncope
Cardiac Non Cardiac
Neurally Mediated
Arrhythmia Obstructive Neurological Other
Causes
Syncope in Older PeopleSyncope in Older People
HistoryHistory, Exam, ECG, Orthostatic BP, CSM
Syncope, Not Syncope
Cardiac, Neurally Mediated, Inconclusive
Risk Stratification
Without accurate history correct Without accurate history correct routing for stratification routing for stratification unlikelyunlikely
The history history is critical :
•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible causes•Establishing the prognosis•Expediting accurate treatment
• FallsFalls• TIATIA• EpilepsyEpilepsy
ECS Taskforce recommendations 2010
ChallenChallengege
Syncope presents as falls
Falls are common
Both Syncope and Falls increase with age
But which ‘Falls’ are ‘Syncope’
Why Falls and Syncope overlap
Which Falls ‘pace’ if any
Therefore……How to Attribute Cause?Therefore……How to Attribute Cause?
Falls and syncope
are common
60% one 20% 2 20% > 223% unexplained 32% injury6% blackout/near blackout past year
n=8570n=8570 > > 505058% 50-6558% 50-65mean age 62mean age 62
www.tilda.iewww.tilda.ie
20% fall past year
The Irish Longitudinal StuDy on AgeingThe Irish Longitudinal StuDy on Ageing
Accuracy of history is Accuracy of history is less likely with less likely with
advancing age- advancing age- rising prevalence cognitive
impairment and dementia
Age-related Cognitive Decline- poor Age-related Cognitive Decline- poor history/recallhistory/recall
Salthouse (2006) Perspectives on Psychological Science
MemoryMemoryConcentrationConcentrationReactionReactionExecutive fctExecutive fct
VocabularyVocabulary
Prevalence of Cognitive ImpairmentCognitive Impairment and DementiaDementia, by Age (ADAMS Study)
0%
20%
40%
60%
80%
100%
70 75 80 85 90 95
CIND
Demented
Dementia
Cognitive impairment
YEARS
‘If episodes are witnessed then the collateral history
will suffice..’
ButBut > 70% episodes (Falls or Syncope) in > 70% episodes (Falls or Syncope) in Persons 70 years and older are NOT Persons 70 years and older are NOT witnessed.witnessed.
Amnesia for LOCAmnesia for LOC can also occur can also occur independent of Impaired Cognition independent of Impaired Cognition
Amnesia for loss of consciousness (A-LOC)
in n= 159 with Vasovagal Syncope during tilt induced LOC
ALOCALOC No No
ALOCALOC
P
age 55±22 44±19 0.003
prodrome
with real
time
syncope
26
(59%)
98 (85%) 0.001
fracture
with
syncope
34% 17% 0.02
O'Dwyer C, Kenny et al. Europace 2011;13:1040-1045
Drop Attacks in Older Adults: Systematic Assessment Has a High
Diagnostic YieldSteve W Parry, Rose Anne Kenny JAGS 2009
S W Parry RA Kenny JAGS 2009
CardiovascularCardiovascular 49 (53%)
carotid sinus syndrome 37 (40%)
arrhythmias, OH, VVS 12 (12%)
NeurologicalNeurological 44 (44%)
MedicationsMedications 11 (12%)
Others5 (5%)
>one>one 23 (18%)23 (18%)
Unexplained 10 (19%)
Drop Attacks in Older Adults:
Attributable Diagnosesn=93, 80% Female, mean 10, 34% fracture
Epilepsy/Syncope
Syncope in Older PeopleSyncope in Older People
HistoryHistory, Exam, ECG, Orthostatic BP, CSM
Syncope, Not Syncope
Cardiac, Neurally Mediated, Inconclusive
Risk Stratification
Without accurate history correct Without accurate history correct routing for stratification routing for stratification unlikelyunlikely
The history history is critical :
•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible causes•Establishing the prognosis•Expediting accurate treatment
• FallsFalls• EpilepsyEpilepsy• TIATIA
ECS Taskforce recommendations 2010
74 adult patients
HUT, CSM, EEG, BP
ILS in some
31 (4242%) alternative diagnosis 20 VVS 2 psychogenic 7 CSH 2 bradycardia
“ Many Seizure-Like Attacks Have a Cardiovascular Cause”
Zaidi et al 2000
Cardiologist: Zaidi et al, 2000
• 184 adult patients• Clinical review• 46 (2222%) alternative
diagnosis– 14 VVS
– 7 other
– 6 mixed
– 1 unknown
• 31 children• HUT, CSM, ECG, BP• 19 (6161%) alternative
diagnosis– 9 VVS
– 7 LQTS
– 1 psychogenic
– 2 CSH
– 2 bradycardia
Pediatrician: Akhtar 2002Neurologist: Smith et al, 2002
Epilepsy
40% 40% treatment resistant seizurestreatment resistant seizures cardiovascular cardiovascular
Assessment- Assessment- Poor recall, Amnesia LOC, No collateralPoor recall, Amnesia LOC, No collateral
History, Exam, ECG, Orthostatic BP, CSM
Syncope, Not Syncope
Cardiac, Neurally Mediated, Inconclusive
Risk Stratification
The history history is critical :•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible c auses•Establishing the prognosis•Expediting accurate treatment
•FallsFalls
TIATIA
•EpilepsyEpilepsy
30% patientsReferred TIA clinicReviewed Syncope/Falls
Focal neurology among syncope patientsD J Ryan, C P Rice, J A Harbison, R A Kenny
405 consecutive VVS patients
6% focal neurology hypotension
47 yrs 77% female.
monoparesis/dysasthesia (12), hemiparesis/dysasthesia (7), isolated facial droop (4).
Median 5 min median 15 events
Hypotensive symptoms preceded neurology in 30%
time of onset 40%
3:1 case controls
childhood syncope (p=0.006) ? burden
Older people are more susceptible to haemodynamic stroke
D J Ryan, S Christensen, J F Meaney, A Fagan, R A Kenny, J A Harbison
all acute strokes prospective screen presyncope or syncope at stroke onset in ER
402 stroke patients ER
severe carotid stenosis excluded.
3T MRI with perfusion imaging (BZI)
syncope unit
5.1% presyncope/syncope at stroke onset - 74 yrs.
57% TIA rather than a stroke.
hypotensive symptoms, mean 5 yrs,
VVS 61%, sustained OH 25%, cardiac syncope in 11%
15 acute infarct on MRI, 11 (73%) borderzone region – episodic hypotension causal
BZI older (80 yrs in BZI group Vs 69 yrs no BZI, p=0.006).
Blood pressure drop on active stand in the BZI group was greater than those without a BZI (p=0.01).
Older people are more susceptible to haemodynamic stroke
D J Ryan, S Christensen, J F Meaney, A Fagan, R A Kenny, J A Harbison
Episodic hypotension potentiates stroke, even in those without carotid disease. Older people that experience frequent postural symptoms are particularly vulnerable. ? over-zealous anti-hypertensive therapy in this group.
Older people are more susceptible to haemodynamic stroke
D J Ryan, S Christensen, J F Meaney, A Fagan, R A Kenny, J A Harbison
While aggressive hypertension prevention clearly benefits the brains in middle adult years, it is less clear whether aggressive prevention benefits the brains of the older old.