A multidisciplinary approach to identifying syncope in the elderlyProfessor 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 Better Environments 3 mths per year 5 hours per day Female life expectancy in the record-holding country from 1840 to the present 50% females born today Live to 100yrs or beyond
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
Falls & Syncope are Common& Consequences are important Reasons for ER attendance >75 yr (UK, Italian) 21% general decline 15% SOB 15% Falls 13% Abdo Pain 9% Chest Pain 7% Syncope 5% Stroke More common than Stroke or Chest Pain - and taken together - the commonest presentation
Epidemiology Syncope 40-59y 15% < 18y 25% 17-26y military 16% m 19% f 23% nursing home per 1000 person years Adults: 6.2 70-79 : 11 > 8019 ECS Eur Ht J 2004 ER Soteriades NEJM 2002 Weiling 02
Causes- more common advancing age Causes • Neurally mediated • Orthostatic • Cardiac Arrhythmia • Structural • Cerebrovascular Comorbid/Triggers Medications Dehydration Physiological changes (Neurohumoral, Renal) Locomotor (gait, balance, joint) 30% > 70s > one possible attributable cause
Syncope Cardiac Non Cardiac Neurally Mediated Arrhythmia Obstructive Neurological Other Causes Syncope
Syncope in Older People • The history is critical : • Eliminating other diagnoses • Discriminating among causes of syncope • Finding reversible causes • Establishing the prognosis • Expediting accurate treatment • Falls • TIA • Epilepsy History, Exam, ECG, Orthostatic BP, CSM • Syncope, Not Syncope Cardiac, Neurally Mediated, Inconclusive • Risk Stratification Without accurate history correct routing for stratification unlikely ECS Taskforce recommendations 2010
Challenge • 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?
The Irish Longitudinal StuDy on Ageing Falls and syncope are common n=8570 > 50 58% 50-65 mean age 62 60% one 20% 2 20% > 2 23% unexplained 32% injury 20% fall past year 6% blackout/near blackout past year www.tilda.ie
Accuracy of history is less likely with advancing age- rising prevalence cognitive impairment and dementia
Age-related Cognitive Decline- poor history/recall Vocabulary Memory Concentration Reaction Executive fct Salthouse (2006) Perspectives on Psychological Science
Prevalence of Cognitive Impairment and Dementia, by Age (ADAMS Study) Cognitive impairment Dementia YEARS
‘If episodes are witnessed then the collateral history will suffice..’ But> 70% episodes (Falls or Syncope) in Persons 70 years and older are NOT witnessed. Amnesia for LOCcan also occur independent of Impaired Cognition
Amnesia for loss of consciousness (A-LOC) in n= 159 with Vasovagal Syncope during tilt induced LOC 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
Drop Attacks in Older Adults: Attributable Diagnosesn=93, 80% Female, mean 10, 34% fracture Cardiovascular 49 (53%) carotid sinus syndrome 37 (40%) arrhythmias, OH, VVS 12 (12%) Neurological 44 (44%) Medications 11 (12%) Others 5 (5%) >one 23 (18%) Unexplained 10 (19%)
Syncope in Older People • The history is critical : • Eliminating other diagnoses • Discriminating among causes of syncope • Finding reversible causes • Establishing the prognosis • Expediting accurate treatment • Falls • Epilepsy • TIA History, Exam, ECG, Orthostatic BP, CSM • Syncope, Not Syncope Cardiac, Neurally Mediated, Inconclusive • Risk Stratification Without accurate history correct routing for stratification unlikely ECS Taskforce recommendations 2010
Epilepsy “ Many Seizure-Like Attacks Have a Cardiovascular Cause” • 74 adult patients • HUT, CSM, EEG, BP • ILS in some • 31 (42%) alternative diagnosis • 20 VVS • 2 psychogenic • 7 CSH • 2 bradycardia Zaidi et al 2000 • 31 children • HUT, CSM, ECG, BP • 19 (61%) alternative diagnosis • 9 VVS • 7 LQTS • 1 psychogenic • 2 CSH • 2 bradycardia • 184 adult patients • Clinical review • 46 (22%) alternative diagnosis • 14 VVS • 7 other • 6 mixed • 1 unknown 40% treatment resistant seizures cardiovascular Cardiologist: Zaidi et al, 2000 Neurologist: Smith et al, 2002 Pediatrician: Akhtar 2002
Assessment- Poor recall, Amnesia LOC, No collateral • The history is critical : • Eliminating other diagnoses • Discriminating among causes of syncope • Finding reversible c auses • Establishing the prognosis • Expediting accurate treatment • Falls • TIA • Epilepsy History, Exam, ECG, Orthostatic BP, CSM • Syncope, Not Syncope Cardiac, Neurally Mediated, Inconclusive • Risk Stratification 30% patients Referred TIA clinic Reviewed 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 yrs77% female. monoparesis/dysasthesia (12),hemiparesis/dysasthesia (7), isolated facial droop (4). Median 5 minmedian 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 strokeD J Ryan, S Christensen, J F Meaney, A Fagan, R A Kenny, J A Harbison • all acute strokes prospective screen presyncopeor 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 strokeD 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 strokeD 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.
Conclusion: Syncope more common with advancing years Cardiac causes more common Falls and syncope overlap Amnesia for LOC increases age but also VVS young Vasovagal syncope can be associated with Epilepsy type Movements Syncope can be associated with focal neurology Stroke/TIA associated with hypotensive episodes Management Syncope same young Old- arttributable diagnosis Is a challenge