Syncope in Elderly. Dr Matthew Fay General Practitioner NHS-Improvement Clinical Lead. Westcliffe Medical Practice Shipley

Transcription

1 Syncope in Elderly Dr Matthew Fay General Practitioner NHS-Improvement Clinical Lead

2 SYNCOPE Syncope (Greek: synkope = cut-off) is a brief transient loss of consciousness (fainting) and postural tone (collapse) with rapid spontaneous recovery

3 SYNCOPE From National Health Ambulatory Medical Survey of Emergency Department (ED) visits in USA million ED pt.( 0.65% of all visits) with the diagnosis of syncope unrelated to injury 1.1 million pt.(40.8%) were 65 yrs or older 63.8% were female Among pt. older than 65 yrs, admit rate for syncope was 61.8% and was the sixth most common admission diagnosis

4 Incidence of syncope in the Framingham Heart Study Men Women >80

5 SYNCOPE Age-dependent morphological and physiological changes Old patients often take drugs (sedatives, diuretics, vasodilators, anti-hypertensives) Old patients display a higher incidence of chronic pathologies such as diabetes mellitus, congestive heart failure, coronary disease, cerebrovascular pathologies and multiple sensorial deficiency.

6 Age-related physiological changes that predispose to syncope Blood vessel Heart Autonomic nervous system Other non cardiological changes

7 Heart Age-related stiffening of arterial vessels produces high afterload. Ventricular walls become more fibrotic and noncompliant leading to ventricular diastolic dysfunction. LV systolic dysfunction is also common because of the high prevalence of HTN and IHD among the elderly Increase incidence of age-related mitral and aortic valvular diseases.

8 Heart A progressive fall in the ratio of nodal myocytes to collagenous stroma with age particularly in the sinus node increases the incidence of AF, heart block and sick sinus syndrome.

9 Blood vessel Atherosclerosis is also universally present in older humans Impair endothelial-dependent nitric oxide release Increase endothelin release in the ageing vessels This impairs both the cardiac and cerebral circulation which may predispose to syncope in the elderly.

10 Autonomic nervous system Beta-adrenergic response to plasma noradrenaline is blunted in the elderly Diminished beta-1 responses lead to reduced cardioacceleration and cardiac contractility Diminished beta-2 results in increased vascular tone because of the unopposed alpha-1 vasoconstriction. Baroreflex mediated cardioacceleration is also reduced

11 Autonomic nervous system HR increase in response to stress is less effective. Sympathetic and parasympathetic autonomic responses are reduced in health ageing Blunted autonomic responses together with other factors including dehydration, vasodilator medications, sodium wasting may result in orthostatic hypotension, cerebral underperfusion and syncope in the elderly.

12 Other non cardiological change Plasma renin and aldosterone fall with age and this results in sodium wasting. impaired thirst response of many elderly people to hyperosmolality may cause hypovolaemia and consequent orthostatic hypotension

13 Causes of syncope of the elderly Cardiac diseases - Primary cardiac arrhythmias - Structural cardiovascular diseases obstruction to left ventricular outflow - Obstruction to right ventricular outflow Neurally mediated syncopal syndromes - Vasovagal syncope - Situational syncope - Carotid sinus hypersensitivity Orthostatic and dysautonomic disturbance of blood pressure control Postprandial hypotension Cerebrovascular, neurological, and psychiatric causes

14 Primary cardiac arrhythmias Probably the most common cause of syncope in patients with structural heart or vascular disease. An age-related fall in nodal myocytes particularly in the sino-atrial node increases the incidence of atrial fibrillation, heart block and sick sinus syndrome Polypharmacy

15 Drugs predisposing to syncope Vasodilators: nitrates, Calcium Channel Blockers, ACEIs Antihypertensives : Alpha Blockers, Beta Blockers Prolongation of QT(torsade de pointes) - Antiarrhythmic agent : class IA,III - Antibiotics : macrolide(erythromycin), bactrim - Others :Terfenadine,Tricyclic Antidepressants

16 Conditions predisposing to a prolonged QT interval and torsade des pointes Acquired causes Ischemic coronary artery disease Enviromental and endocrinological causes Medicinal and toxicological causes Hypothermia Class 1A antidysrhythmics - quinidine, procainamide, disopyramide Congestive heart failure Bulemia, stringent dieting Class 1C antidysrhythmics - flecainide, encainide Neurological causes Subarachnoid hemorrhage Cerebrovascular occlusive disease Rheumatic heart disease Hypothyroidism Phenothiazine overdose Traumatic brain injury Myocarditis Hypokalemia Butyrophenone overdose Encephalitis Hypocalcemia Hypomagnesemia Tetracyclic/tricyclic antidepressant overdose Organophosphate overdose Macrolide antibiotics + terfenadine or astemizole or cisapride Azole antifungals + terfenadine or astemizole or cisapride

17 Structural cardiovascular diseases obstruction to left ventricular outflow Aortic stenosis is the most common structural lesion associated with syncope in the elderly - Age < 70 yr.: Congenital bicuspid valves - Age > 70 yr.: Degenerative changes Hypertrophic obstructive cardiomyopathy (HOCM) Vasodilator drugs or even vasodilatation after a hot bath can induce syncope in these patients

18 Situational syncope Peripheral receptors similar to ventricular mechanoreceptors are found in lung, bladder, GI tract Cough or micturition related syncope

19 Carotid sinus hypersensitivity 20% of older people who presented with unexplained syncope (Parry and Eltrafi). Defined as asystole of 3 s or more and/or a decrease in systolic pressure of 50 mmhg or more during carotid sinus massage.

20 Orthostatic and dysautonomic disturbance of BP control 30% of community-dwelling adults over 75 years of age have orthostatic hypotension (Lipsitz, 1989). Autonomic failure such as multiple system atrophy and diabetes mellitus. The combination of the blunted age-related autoregulatory changes, medications (diuretic, vasodilators), and chronic diseases predispose older adults to orthostatic hypotension.

21 Postprandial hypotension 8% of syncope cases in older nursing home patients in one study (Jansen et al., 1995). Defined as 20 mmhg or greater decline in systolic blood pressure within 90 min after a meal. Common in older adults and can coexist with orthostatic hypotension in the same individual ( Jansen and Lewis, 1995). Pathophysiological mechanism of postprandial hypotension is still a matter of debate.

22 Differentiating syncope from seizure Feature Syncope Seizure Aura Absent Rarely present Dizziness prodome Sometimes present Absent Color at onset of event Sometimes pale Sometimes purple Jerking movements Infrequent & short-lived Common & longer-lasting Pattern of convulsion Uncoordinated myoclonic jerks & twitches after LOC GTC movementscoincidence with LOC Upturning of eyes Common Uncommon Forced conjugate deviation of eyes Absent Common Tongue biting lateral Absent Common Urinary incontinence Rare Common Duration of event Seconds Minutes Disorientation after event Absent rare Increase in CK enzyme Absent Present Present common

23 History An eye-witness account is very important mode of onset and progression of event Body position at onset of event Depth of altered consciousness Duration of the syncopal episode Rate of recovery of consciousness Identify any precipitants including meals, pain, cough, micturition, defaecation, swallowing, postural change, neck movement and exercise

24 History Associated symptoms such as palpitation, dyspnoea, chest pain History of panic attack and hyperventilation pscyhological triggering events (painful stimuli, sudden bad news) Drug history is obviously important. Past medical history and risk factors for ischaemic heart disease

25 Clinical clue Sudden syncope at rest when nonerect Sudden syncope on exertion Preceding "lightheadness" prodrome when erect Preceding palpitations Preceding or accompanying dyspnea Westcliffe Medical Practice CLINICAL CLUE TABLE Suggest Cardiac arrhythmia, atrial myxoma Aortic stenosis, HOCM, atrial myxoma, malignant cardiac arrhythmia Vasovagal syncope, orthostatic hypotension Cardiac arrhythmia PE, tension pneumothorax, cardiac tamponade, air embolism Preceding or accompanying chest pain AMI, PE, cardiac tamponade, dissecting aneurysm, tension pneumothorax, mitral valve prolapse Preceding or accompanying back pain Preceding or accompanying abdominal pain Dissecting aortic aneurysm, leaking AAA Leaking AAA, ectopic pregnancy

26 CLINICAL CLUE TABLE Clinical clue Occurring when turning head to side, or looking up Occurring when exercising upper arm Occurring during (or immediately after) coughing, laughing, vomiting, swallowing, urination, defecation, combing hair, stretching Occurring after prolonged standing Occurring after emotional upset Polypharmacy, recent sialdenafil use Recent fluid loss (diarrhea, vomiting, sweating) Recent meal Suggest Carotid sinus syncope Subclavian steal syndrome Situational syncope Vasovagal syncope Vasovagal syncope, prolonged QT interval and torsade Orthostatic syncope Orthostatic hypotension Postprandial hypotensive syncope

27 Clinical clue Westcliffe Medical Practice CLINICAL CLUE TABLE Suggest History of known cardiac ischemia or structural heart disease History of mechanical heart valve Recent history of cancer, prolonged immobilization, leg injury or surgery History of autonomic dysfunction (impotence, anhydrosis, sphincter dysfunction) History of recurrent syncope Family history of syncope or sudden death Pacemaker Cardiac arrhythmia, pro-arrhythmia drug effect, valve dysfunction Thrombosis of valve Pulmonary embolism Orthostatic hypotension secondary to autonomic neuropathy Cardiac arrhythmia, carotid sinus syncope, atrial myxoma, aortic stenosis, subclavian steal syndrome, prolonged QT interval - torsade HOCM, prolonged QT syndrome Pacemaker failure

28 Falls - the size of the problem Each year 30% of those aged over 65, 40% over 80yo living in the community and 60% of nursing home residents will fall (Shaw 1996) 400,000 older people attend A&E in England because of an accident (DTI 1997, O Loughlin 1993) One third of those aged over 50 yrs age attending Newcastle s A&E do so because of a fall: 10,000 people each year (Richardson 2001). Older people who have fallen are at risk of falling again. Many elderly fallers don t seek help or don t get further assessed.

29 Falls - the size of the problem 15% falls result in serious injury Leading cause of mortality due to injury in over 75yo in UK (HEA 1999) 5% falls result in fracture 1% hip (Tinetti 1988, O Loughlin JL 1993) 1/3 hip fractures can no longer live independently and 25% are dead at 6 months 14,000 people die every year from hip # in UK (Melton 1998)

30 Why do Syncope and falls overlap syncope amnesia cognitive impairment cerebral hypoperfusion results in gait and balance disturbance

31 Overlap between Syncope and falls Evidence: Anecdotal Case series 20% of cardiovascular syncope present with falls Individuals with CSS had reduction in falls as well as syncopal events after pacing Safe Pace 1 2/3 reduction in falls in recurrent unexplained fallers with CICSH after pacing 3% all falls are syncope (Rubenstein 1996)

32 Overlap between Syncope and falls Consider in unexplained and recurrent fallers (18% of AE attendees) as 55% have a cardiovascular attributable cause Especially with significant injury or a prodrome of dizziness or if lack of recollection how ended up on the ground

33 Orthostatic hypotension definition? 20mmHg fall in systolic blood pressure OR 10mmHg fall in diastolic blood pressure within 2 minutes of standing

34 Orthostatic (Postural) hypotension diagnosis The Active Stand test Morning 10 minute rest Anaeroid sphygmanometer is sufficient May need two or even three people Rapid stand Repeated BPs over 2-3 minutes Repeat measurements may be needed, orthostatic response variable time of day and day to day Beat to Beat BP monitoring facilitates detection

35 Don t forget rare causes of OH Illness Fever, dehydration, acute blood loss and anaemia Prolonged bed rest Inadequate fluid intake Culprit medications 28% Age related 20% Autonomic failure: - if no clear explanation consider AFTs Primary 24% Multisystem atrophy 13% Diabetes 3% Parkinson s Disease 5% Cardiovascular disease 5% Addisons - worth checking cortisol/ synachten test Undiagnosed 2%

36 Orthostatic hypotension non drug management for all.. Conservative advice Fluids Take your time Exercise pre stand Salt No Crossed legs Squatting Alcohol Large CHO meals Don t strain at stool Sit to wee Cognisance of precipitating factors Graduated compression stockings/tights Abdominal binders

37 OH Management refractory cases Caffeine 2 cups in the morning Raise head end of bed (RAS activation) Bannister 1969 Abdominal binders Specific drugs Fludrocortisone Midodrine NSAIDs SSRIs Others

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39 Thank you for your attention Question