Syncope in the Elderly Assessment and Treatment Professor Rose Anne Kenny Trinity College Dublin Newcastle University
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
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%
Epidemiology Incidence Adults: 6.2 per 1000 person years 70-79 : 11 per 1000 person years > 80 19 per 1000 person years Soteriades NEJM 2002
Syncope in the Elderly Why more common in Ageing? Age related physiology Comorbidity Medications Age related pathology- cardiac and neurodegeneration
Classification Neurally mediated Orthostatic Cardiac Arrhythmia Structural Heart Disease Cerebrovascular
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
Classification Orthostatic Primary Autonomic failure syndromes (PAF, MSA, PD,? POTS) Secondary Autonomic failure (DM, drugs, Alcohol Amyloid) Volume depletion (Haemorrhage, diarrhoea, Addison's,?Age)
Classification Cardiac Arrhythmias as primary cause SND AV Conduction PSVT, VT Inherited Syndromes (Long QT, Brugada) Implanted device malfunction Drug Induced Arrhythmia
Classification Structural Cardiac/Cardiopulmonary Cardiac Valvular Acute MI Obstructive cardiomyopathy Atrial Myxoma Acute Aortic dissection Pericardial Pulmonary Embolus/ Hypertension Cerebrovascular Vascular Steal Syndromes
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
Cardiovascular Assessment methods
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
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
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
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
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
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
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
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
Syncope and Falls in the Elderly Atypical presentations syncope Syncope presenting as falls 70% events > 70yrs unwitnessed, No collateral history McIntosh 99
Syncope and Falls in the Elderly After 50 yrs 3% per year loss muscle strength 70-74 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
Falls / Syncope Overlap Syncope amnesia unwitnessed Falls gait/balance instability and acute hypotension
Accident and Emergency 71, 000 >50 years Non-Fallers 59% Richardson Pace 1999 Richardson Bond JACC 2001 Syncope / Fall 34% (n = 24,237)
Accident and Emergency > 65 yrs Syncope/ Fall 45% (n=4793)
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
Risk Factors in Recurrent Accidental Falls 100 Balance 90 % with risk factor 80 70 60 50 40 30 Gait Medication Home Hazards CSH OH Arrhythmia 20 10 Vasovagal 0 Davidson Age Ageing 05
Recurrent Accidental Falls (n=386) RCT (one year) Intervention Control 340 falls 1320 falls Davidson Age Ageing 05
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
Risk Factors in Cognitively Impaired Fallers % of patients with each risk factor 100 Balance/gait 80 60 40 20 0 Environment Medication Intervention - NS Neurocard / Arrhythmia Feet/footwear Medical Vision Risk factor Depression Other Shaw BMJ 2002
Newcastle Accident and Emergency Study Drop Attacks 18% no effective tx
Drop Attacks Percentage 70% 60% VDCSH 1 in 4 CICSH n = 76 n = 9 50% CICSH n = 124 40% n = 179 30% n = 157 n = 183 20% n = 122 n = 130 n = 130 10% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 Age Group Richardson Bexton Kenny PACE 1998
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
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
Infrastructure for Best Practice - Syncope Evaluation is haphazard and unstratified Specialties- cardiology, neurology, geriatric, emergency medicine Variation diagnostic tests attributable diagnoses % unexplained syncope
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%
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
Infrastructure for Best Practice Newcastle Model Rapid Access One Site One Stop Education/Communication Stakeholders -6005 bed days 6005 bed days at variance with peer hospital (2001)
Performance / Activity Newcastle Sites Number Episodes % Emergency % Elective Average LoS (days) 13 1249 99 0.5 5 NCL 1105 37 62 2 8 1099 97 3 17 Savings Site 8 3million Kenny Age Ageing 02 1991 Length of stay 10 vs 2 days zero vs 62% elective activity saving 31 acute beds in year
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
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
Setting up a falls and syncope service Equipment- laboratory, ambulatory Neurally mediated Cardiac Gait/Balance
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.