syncope in the elderly – assessment and treatment€¦ · 3°step ep study 4°step csm - tilt...

Syncope in the Elderly Syncope in the Elderly ––

Assessment and TreatmentAssessment and Treatment

Professor Rose Anne Kenny

Trinity College Dublin

Newcastle University

DefinitionDefinition

Syncope is a syndrome consisting of a Syncope is a syndrome consisting of a

relatively relatively short periodshort period of of temporarytemporary

and and self limitedself limited loss of consciousnessloss of consciousnesscaused by transient reduction in blood flow to the

brain (most often the result of systemic

hypotension).

• Transient

• Spontaneous recovery

EpidemiologyEpidemiology

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%

EpidemiologyEpidemiology

IncidenceIncidence

• 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 ElderlySyncope in the Elderly

Why more common in Ageing?Why more common in Ageing?

• Age related physiology

• Comorbidity

• Medications

• Age related pathology- cardiac and neurodegeneration

ClassificationClassification

• Neurally mediated

• Orthostatic

• Cardiac Arrhythmia

• Structural Heart Disease

• Cerebrovascular

ClassificationClassification

NeurallyNeurally MediatedMediated• Vasovagal Syncope

• Carotid sinus Syncope

• Situational FaintAcute haemorrhage

Cough, sneeze,

Gastrointestinal stimulation

Micturition

Post exercise

Other (brass instrument play, weight lifting, postprandial)

• Glossopharyngeal and trigeminal neuralgia

ClassificationClassification

OrthostaticOrthostatic

• Primary Autonomic failure syndromes (PAF, MSA, PD, ? POTS)

• Secondary Autonomic failure

(DM, drugs, Alcohol Amyloid)

• Volume depletion

(Haemorrhage, diarrhoea, Addison's, ?Age)

ClassificationClassification

Cardiac Arrhythmias as primary causeCardiac Arrhythmias as primary cause

• SND

• AV Conduction

• PSVT, VT

• Inherited Syndromes (Long QT, Brugada)

• Implanted device malfunction

• Drug Induced Arrhythmia

ClassificationClassification

Structural Cardiac/CardiopulmonaryStructural Cardiac/Cardiopulmonary• Cardiac Valvular

• Acute MI

• Obstructive cardiomyopathy

• Atrial Myxoma

• Acute Aortic dissection

• Pericardial

• Pulmonary Embolus/ Hypertension

CerebrovascularCerebrovascular• Vascular Steal Syndromes

Syncope in the ElderlySyncope in the Elderly

Causes >65Causes >65Secondary syncope facility- open access ER and GPs

OH – 30%

VVS- 30%

CSH- 20%

Arrhythmia-20%

More than one possible attributable causeMore than one possible attributable cause 1/31/3

Alcock OShea 98

Cardiovascular AssessmentCardiovascular Assessment

methodsmethods

Number of Investigations before dx

in ‘Syncope’Investigations Diagnosis AchievedInvestigations Diagnosis Achieved

• History and examination 1.6• Holter monitoring 9.8• R Test 2.6

•• CT brain 87CT 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 EEG not dxdx

•• Carotid Carotid DopplersDopplers not not dxdx

Farewell Heart 05

Syncope/Falls/DizzinessSyncope/Falls/Dizziness

History, physical examination, ECG, SBP supine and upright,

carotid sinus massage, blood chemistry and haematologyInitial evaluation

Diagnostic

Treatment

Inconclusive

Cerebrovascular Psychiatric

Suggestive

Cardiac Neurally-mediated

Syncope/Unexplained fallsSyncope/Unexplained falls (?)

History, physical examination, ECG, SBP supine and upright,

carotid sinus massage, blood chemistry and haematologyInitial evaluation

Diagnostic

Treatment

InconclusiveSuggestive

Cardiac

2°stepEcho - 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 fallsSyncope/Unexplained falls (?)

History, physical examination, ECG, SBP supine and upright,

carotid sinus massage, blood chemistry and haematologyInitial evaluation

Diagnostic

Treatment

InconclusiveSuggestive

Cardiac Neurally-mediated

CSM - Tilt test - ATP test

Echo - Holter

EP study

(if heart disease)

Consider other causes

Infrequent Frequent

Loop ECGStop

work-up

Psychiatric evaluation

EEG - CT scan - MRI scan

Doppler ultrasonography

Consider other causes

Syncope/Unexplained fallsSyncope/Unexplained falls (?)

History, physical examination, ECG, SBP supine and upright,

carotid sinus massage, blood chemistry and haematologyInitial evaluation

Diagnostic

Treatment

Inconclusive

Cerebrovascular Psychiatric

Suggestive

Cardiac Neurally-mediated

CSM - Tilt test - ATP test

Echo - Holter

2°stepEcho - Holter,

Stress test? Lung scan?

3°step EP study

4°step CSM - Tilt test - ATP test

Consider other causes

5°step Loop ECG

CSM - Tilt test - ATP test

Echo - Holter

EP study

(if heart disease)

Consider other causes

Infrequent Frequent

Loop ECGStop

work-up

Consider other causes

Infrequent Frequent

Loop ECGStop

work-up

Transient Loss of Transient Loss of

ConsciousnessConsciousness

TLOC

TraumaConcussion

May not be transientNo trauma

Intoxication

Metabolic

Subarachnoid

Epilepsy

TLOC

No trauma

SyncopeEpilepsySteal

Psychogenic

Cataplexy

Drop Attacks

UnconsciousnessApparent

Unconsciousness

Syncope Syncope vsvs EpilepsyEpilepsy

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 Syncope vsvs TIATIA

• 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 Syncope and Falls Falls in the Elderlyin the Elderly

Atypical presentations syncopeAtypical presentations syncope

‘‘Syncope presenting as fallsSyncope presenting as falls’’

70% events > 70yrs unwitnessed,

No collateral history

McIntosh 99

Syncope and Falls in the ElderlySyncope and Falls in the Elderly

After 50 yrs

3% per year loss muscle strength

7070-- 74 yrs74 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 BPTransient arrhythmias/low BP…….falls .falls

Falls / SyncopeFalls / Syncope

Overlap

SyncopeSyncope amnesia

unwitnessed

Falls Falls gait/balance instability

and acute hypotension

Accident and Emergency

Syncope / Fall 34%(n = 24,237)

Non-Fallers 59%

71, 000 >50 years

Richardson Pace 1999Richardson Bond JACC 2001

Syncope/ Fall 45% (n=4793)

Accident and Emergency

> 65 yrs

Accident and Emergency

Cognitively Impaired Cognitively Impaired

25%25%

AccidentalAccidental

35%35%

Medical Diagnosis

22%22% Drop Attacks 18%Drop Attacks 18%

Richardson PACE 1999, Age Ageing 2001

Davies Age Ageing 1999, Parry JAGS 2005

Risk Factors in Recurrent Accidental Falls

0

10

20

30

40

50

60

70

80

90

100

% with risk

factor

Balance

Gait

Home Hazards

Vasovagal

Medication

Davidson Age Ageing 05

CSH

OH

Arrhythmia

Recurrent Accidental FallsRecurrent Accidental Falls (n=386)

RCT (one year)

Intervention Control

340 falls340 falls 1320 falls1320 falls

Davidson Age Ageing 05

Accident and Emergency

Cognitively Impaired Cognitively Impaired

25%25%

AccidentalAccidental

35%35%

Medical Diagnosis

22%22% Drop Attacks 18%Drop Attacks 18%

Richardson Kenny PACE 1999, Age Ageing 2001

Davies Kenny Age Ageing 1999, Parry Kenny JAGS 2005

Risk factor

Risk Factors in Cognitively Impaired Fallers

0

20

40

60

80

100 Balance/gait

NeurocardNeurocard / Arrhythmia/ Arrhythmia

Environment

Medication

Feet/footwear

VisionMedical

Depression

% o

f p

atie

nts

with

each

ris

k fa

cto

r

Other

Shaw BMJ 2002

Intervention Intervention -- NSNS

Newcastle Accident and Emergency StudyNewcastle Accident and Emergency Study

Drop Attacks 18%Drop Attacks 18%

‘‘no effective no effective txtx’’

0%

10%

20%

30%

40%

50%

60%

70%

50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 85 - 89 90 - 94

Age Group

Percentage

80 - 84

VDCSH

CICSH

n = 122

n = 9

n = 76

n = 124

n = 130

n = 130

n = 157n = 183

n = 179

1 in 4 CICSH

Drop Attacks

Richardson Bexton Kenny PACE 1998

What are the interventionsWhat are the interventions

• Conservative Advise- avoid provoking situations, increase fluid intake, exercise

• Stop or Reduce medications (cardiovascular/psychotropic)

• Give medications-

low BP (Midodrine, fludrocortisone), antiarrhythmics

• Pacemaker

Syncope Cardiovascular interventions for Falls Syncope Cardiovascular interventions for Falls

Intervention trials for fallsIntervention 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 InterventionEarly Intervention

Infrastructure for Best Practice Infrastructure for Best Practice -- SyncopeSyncope

• Evaluation is haphazard and unstratified

• Specialties- cardiology, neurology, geriatric, emergency medicine

• Variation – diagnostic tests

attributable diagnoses

% unexplained syncope

SyncopeSyncope

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 Infrastructure for Best Practice -- SyncopeSyncope

• 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 days6005 bed days at variance with peer hospital (2001)

Sites NumberEpisodes

%Emergency

%Elective

AverageLoS (days)

13 1249 99 0.5 5

NCL 1105 37 62 2

8 1099 97 3 17

Savings Site 8 Savings Site 8

££3million3million

Performance / Activity Newcastle

1991

Length of stay 10 vs 2 days

zero vs 62% elective activity

saving 31 acute beds in yearKenny Age Ageing 02

Setting up a falls and syncope Setting up a falls and syncope

serviceservice

SourcesSources of referral- capture at risk

• A&E, direct GP, in patients, out patient

LocationLocation Unit

• A&E, Cardiology

Setting up a falls and syncope Setting up a falls and syncope

serviceservice

Management loadManagement load

Nurse practitioners, Multidisciplinary, Triage

Cardiology Team

Neurology Team Geriatric Med Team

Psychiatry/PsychologyPsychiatry/PsychologyENTENT

A&EA&E GPGP

Setting up a falls and syncope Setting up a falls and syncope

serviceservice

Equipment- laboratory, ambulatory

Neurally mediated

Cardiac

Gait/Balance

SummarySummary

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.