Syncope in the Elderly Assessment and Treatment. Professor Rose Anne Kenny Trinity College Dublin Newcastle University

Transcription

1 Syncope in the Elderly Assessment and Treatment Professor Rose Anne Kenny Trinity College Dublin Newcastle University

2 Definition Syncope is a syndrome consisting of a relatively short period of temporary and self limited loss of consciousness caused by transient reduction in blood flow to the brain (most often the result of systemic hypotension). Transient Spontaneous recovery

3 Epidemiology 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%

4 Epidemiology Incidence Adults: 6.2 per 1000 person years : 11 per 1000 person years > per 1000 person years Soteriades NEJM 2002

5 Syncope in the Elderly Why more common in Ageing? Age related physiology Comorbidity Medications Age related pathology- cardiac and neurodegeneration

6 Classification Neurally mediated Orthostatic Cardiac Arrhythmia Structural Heart Disease Cerebrovascular

7 Classification Neurally Mediated Vasovagal Syncope Carotid sinus Syncope Situational Faint Acute haemorrhage Cough, sneeze, Gastrointestinal stimulation Micturition Post exercise Other (brass instrument play, weight lifting, postprandial) Glossopharyngeal and trigeminal neuralgia

8 Classification Orthostatic Primary Autonomic failure syndromes (PAF, MSA, PD,? POTS) Secondary Autonomic failure (DM, drugs, Alcohol Amyloid) Volume depletion (Haemorrhage, diarrhoea, Addison's,?Age)

9 Classification Cardiac Arrhythmias as primary cause SND AV Conduction PSVT, VT Inherited Syndromes (Long QT, Brugada) Implanted device malfunction Drug Induced Arrhythmia

10 Classification Structural Cardiac/Cardiopulmonary Cardiac Valvular Acute MI Obstructive cardiomyopathy Atrial Myxoma Acute Aortic dissection Pericardial Pulmonary Embolus/ Hypertension Cerebrovascular Vascular Steal Syndromes

11 Syncope in the Elderly Causes >65 Secondary syncope facility- open access ER and GPs OH 30% VVS- 30% CSH- 20% Arrhythmia-20% More than one possible attributable cause 1/3 Alcock OShea 98

12 Cardiovascular Assessment methods

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16 Number of Investigations before dx in Syncope Investigations Diagnosis Achieved History and examination 1.6 Holter monitoring 9.8 R Test 2.6 CT 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 dx Carotid Dopplers not dx Farewell Heart 05

17 Syncope/Falls/Dizziness Initial evaluation History, physical examination, ECG, SBP supine and upright, carotid sinus massage, blood chemistry and haematology Diagnostic Treatment Suggestive Inconclusive Cardiac Neurally-mediated Cerebrovascular Psychiatric

18 Syncope/Unexplained falls (?) Initial evaluation History, physical examination, ECG, SBP supine and upright, carotid sinus massage, blood chemistry and haematology Diagnostic Treatment Cardiac Suggestive Inconclusive 2 step Echo - Holter, Stress test? Lung scan? 3 step EP study 4 step CSM - Tilt test - ATP test Consider other causes 5 step Loop ECG

19 Syncope/Unexplained falls (?) Initial evaluation History, physical examination, ECG, SBP supine and upright, carotid sinus massage, blood chemistry and haematology Diagnostic Treatment Cardiac Suggestive Neurally-mediated Inconclusive CSM - Tilt test - ATP test Echo - Holter EP study (if heart disease) Consider other causes Infrequent Stop work-up Frequent Loop ECG

20 Syncope/Unexplained falls (?) Initial evaluation History, physical examination, ECG, SBP supine and upright, carotid sinus massage, blood chemistry and haematology Diagnostic Treatment Suggestive Inconclusive Cardiac Neurally-mediated Cerebrovascular Psychiatric 2 step Echo - Holter, Stress test? Lung scan? CSM - Tilt test - ATP test Psychiatric evaluation EEG - CT scan - MRI scan Doppler ultrasonography CSM - Tilt test - ATP test 3 step EP study Echo - Holter Consider other causes Echo - Holter 4 step CSM - Tilt test - ATP test EP study (if heart disease) Consider other causes Consider other causes Consider other causes Infrequent Frequent Infrequent Frequent 5 step Loop ECG Stop work-up Loop ECG Stop work-up Loop ECG

21 Transient Loss of Consciousness TLOC Trauma Concussion Unconsciousness May not be transient No trauma Intoxication Metabolic Subarachnoid Epilepsy TLOC No trauma Syncope Epilepsy Steal Apparent Unconsciousness Psychogenic Cataplexy Drop Attacks

22 Syncope vs Epilepsy 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

23 Syncope vs TIA TIA does not cause syncope Vertebral Ischemia - rare- neurology Transient cerebral disturbances should not be included in the differential for Syncope Unnecessary Investigations

24 Syncope and Falls in the Elderly Atypical presentations syncope Syncope presenting as falls 70% events > 70yrs unwitnessed, No collateral history McIntosh 99

25 Syncope and Falls in the Elderly After 50 yrs 3% per year loss muscle strength 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 BP.falls

26 Falls / Syncope Overlap Syncope amnesia unwitnessed Falls gait/balance instability and acute hypotension

27 Accident and Emergency 71, 000 >50 years Non-Fallers 59% Richardson Pace 1999 Richardson Bond JACC 2001 Syncope / Fall 34% (n = 24,237)

28 Accident and Emergency > 65 yrs Syncope/ Fall 45% (n=4793)

29 Accident and Emergency Accidental 35% Cognitively Impaired 25% Medical Diagnosis 22% Drop Attacks 18% Richardson PACE 1999, Age Ageing 2001 Davies Age Ageing 1999, Parry JAGS 2005

30 Risk Factors in Recurrent Accidental Falls 100 Balance 90 % with risk factor Gait Medication Home Hazards CSH OH Arrhythmia Vasovagal 0 Davidson Age Ageing 05

31 Recurrent Accidental Falls (n=386) RCT (one year) Intervention Control 340 falls 1320 falls Davidson Age Ageing 05

32 Accident and Emergency Accidental 35% Cognitively Impaired 25% Medical Diagnosis 22% Drop Attacks 18% Richardson Kenny PACE 1999, Age Ageing 2001 Davies Kenny Age Ageing 1999, Parry Kenny JAGS 2005

33 Risk Factors in Cognitively Impaired Fallers % of patients with each risk factor 100 Balance/gait Environment Medication Intervention - NS Neurocard / Arrhythmia Feet/footwear Medical Vision Risk factor Depression Other Shaw BMJ 2002

34 Newcastle Accident and Emergency Study Drop Attacks 18% no effective tx

35 Drop Attacks Percentage 70% 60% VDCSH 1 in 4 CICSH n = 76 n = 9 50% CICSH n = % n = % n = 157 n = % n = 122 n = 130 n = % 0% Age Group Richardson Bexton Kenny PACE 1998

36 What are the interventions Conservative Advise- avoid provoking situations, increase fluid intake, exercise Stop or Reduce medications (cardiovascular/psychotropic) Give medicationslow BP (Midodrine, fludrocortisone), antiarrhythmics Pacemaker

37 Syncope Cardiovascular interventions for Falls Intervention 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 Intervention

38 Infrastructure for Best Practice - Syncope Evaluation is haphazard and unstratified Specialties- cardiology, neurology, geriatric, emergency medicine Variation diagnostic tests attributable diagnoses % unexplained syncope

39 Syncope 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%

40 Infrastructure for Best Practice - Syncope If models of care unchanged diagnosis and treatment will remain inadequate Implementation guidelines inadequate European Society Cardiology Guidelines on Syncope 2001, 2005

41 Infrastructure for Best Practice Newcastle Model Rapid Access One Site One Stop Education/Communication Stakeholders bed days 6005 bed days at variance with peer hospital (2001)

42 Performance / Activity Newcastle Sites Number Episodes % Emergency % Elective Average LoS (days) NCL Savings Site 8 3million Kenny Age Ageing Length of stay 10 vs 2 days zero vs 62% elective activity saving 31 acute beds in year

43 Setting up a falls and syncope service Sources of referral- capture at risk A&E, direct GP, in patients, out patient Location Unit A&E, Cardiology

44 Setting up a falls and syncope service Management load Nurse practitioners, Multidisciplinary, Triage Psychiatry/Psychology Cardiology Team ENT Neurology Team Geriatric Med Team A&E GP

45 Setting up a falls and syncope service Equipment- laboratory, ambulatory Neurally mediated Cardiac Gait/Balance

46 Summary 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.