A A multidisciplinarmultidisciplinary approach to y approach to

identifying identifying syncope in the syncope in the

elderlyelderlyProfessor Rose Anne Professor Rose Anne

KennyKenny St James Teaching St James Teaching Hospital and Trinity Hospital and Trinity

College DublinCollege Dublin

People are living People are living longerlonger

For most of humanity 3-4% > 65yrs100 100 years ago ……….

Female life expectancy in the record-holding

country from 1840 to the present

50% females born today 50% females born today Live to 100yrs or beyondLive to 100yrs or beyond

Better Health CareBetter AwarenessLess StressfulBetter Environments

3 mths per year3 mths per year5 hours per day5 hours per day

DefinitionDefinitionSyncope is a syndrome Syncope is a syndrome

consisting of a relatively consisting of a relatively short short periodperiod of of temporarytemporary and and self self limitedlimited loss of consciousness 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 Falls & Syncope are CommonCommon

& Consequences are & Consequences are importantimportant

Reasons for Reasons for ERER attendance > attendance >7575 yr (UK, Italian) yr (UK, Italian)

21% general decline21% general decline

15% SOB15% SOB

15% 15% FallsFalls

13% Abdo Pain13% Abdo Pain

9% Chest Pain9% Chest Pain

7% Syncope5% Stroke5% Stroke

More common than More common than Stroke or Chest PainStroke or Chest Pain - and - and taken together - the commonest presentation taken together - the commonest presentation

Epidemiology Epidemiology SyncopeSyncope

15% < 18y

25% 17-26y military

16% m

19% f

2323% nursing homenursing home

per 1000 person years

Adults: 6.2

70-79 : 11

> 80 1919

40-59y

Soteriades NEJM 2002

ECS Eur Ht J 2004

Weiling 02

ERER

Syncope and collapse R55 ICD 10 Data England

Syncope and collapse R55 ICD 10 Data England

Epilepsy Hospital ActivityEpilepsy Hospital Activity

Causes- more common Causes- more common advancing ageadvancing age

Neurally mediated

Orthostatic

Cardiac Arrhythmia

Structural

Cerebrovascular

MedicationsMedicationsDehydrationDehydrationPhysiologicalPhysiological changes (Neurohumoral, Renal)Locomotor Locomotor (gait, balance, joint)

30% > 70s > one possible attributable

30% > 70s > one possible attributable

causecause

CausesCauses

Comorbid/TriggersComorbid/Triggers

SyncopeSyncope

Syncope

Cardiac Non Cardiac

Neurally Mediated

Arrhythmia Obstructive Neurological Other

Causes

Syncope in Older PeopleSyncope in Older People

HistoryHistory, Exam, ECG, Orthostatic BP, CSM

Syncope, Not Syncope

Cardiac, Neurally Mediated, Inconclusive

Risk Stratification

Without accurate history correct Without accurate history correct routing for stratification routing for stratification unlikelyunlikely

The history history is critical :

•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible causes•Establishing the prognosis•Expediting accurate treatment

• FallsFalls• TIATIA• EpilepsyEpilepsy

ECS Taskforce recommendations 2010

ChallenChallengege

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?Therefore……How to Attribute Cause?

Falls and syncope

are common

60% one 20% 2 20% > 223% unexplained 32% injury6% blackout/near blackout past year

n=8570n=8570 > > 505058% 50-6558% 50-65mean age 62mean age 62

www.tilda.iewww.tilda.ie

20% fall past year

The Irish Longitudinal StuDy on AgeingThe Irish Longitudinal StuDy on Ageing

Accuracy of history is Accuracy of history is less likely with less likely with

advancing age- advancing age- rising prevalence cognitive

impairment and dementia

Age-related Cognitive Decline- poor Age-related Cognitive Decline- poor history/recallhistory/recall

Salthouse (2006) Perspectives on Psychological Science

MemoryMemoryConcentrationConcentrationReactionReactionExecutive fctExecutive fct

VocabularyVocabulary

Prevalence of Cognitive ImpairmentCognitive Impairment and DementiaDementia, by Age (ADAMS Study)

0%

20%

40%

60%

80%

100%

70 75 80 85 90 95

CIND

Demented

Dementia

Cognitive impairment

YEARS

‘If episodes are witnessed then the collateral history

will suffice..’

ButBut > 70% episodes (Falls or Syncope) in > 70% episodes (Falls or Syncope) in Persons 70 years and older are NOT Persons 70 years and older are NOT witnessed.witnessed.

Amnesia for LOCAmnesia for LOC can also occur can also occur independent of Impaired Cognition independent of Impaired Cognition

Amnesia for loss of consciousness (A-LOC)

in n= 159 with Vasovagal Syncope during tilt induced LOC

ALOCALOC No No

ALOCALOC

P

age 55±22 44±19 0.003

prodrome

with real

time

syncope

26

(59%)

98 (85%) 0.001

fracture

with

syncope

34% 17% 0.02

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

CardiovascularCardiovascular 49 (53%)

carotid sinus syndrome 37 (40%)

arrhythmias, OH, VVS 12 (12%)

NeurologicalNeurological 44 (44%)

MedicationsMedications 11 (12%)

Others5 (5%)

>one>one 23 (18%)23 (18%)

Unexplained 10 (19%)

Drop Attacks in Older Adults:

Attributable Diagnosesn=93, 80% Female, mean 10, 34% fracture

Epilepsy/Syncope

Syncope in Older PeopleSyncope in Older People

HistoryHistory, Exam, ECG, Orthostatic BP, CSM

Syncope, Not Syncope

Cardiac, Neurally Mediated, Inconclusive

Risk Stratification

Without accurate history correct Without accurate history correct routing for stratification routing for stratification unlikelyunlikely

The history history is critical :

•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible causes•Establishing the prognosis•Expediting accurate treatment

• FallsFalls• EpilepsyEpilepsy• TIATIA

ECS Taskforce recommendations 2010

74 adult patients

HUT, CSM, EEG, BP

ILS in some

31 (4242%) alternative diagnosis 20 VVS 2 psychogenic 7 CSH 2 bradycardia

“ Many Seizure-Like Attacks Have a Cardiovascular Cause”

Zaidi et al 2000

Cardiologist: Zaidi et al, 2000

• 184 adult patients• Clinical review• 46 (2222%) alternative

diagnosis– 14 VVS

– 7 other

– 6 mixed

– 1 unknown

• 31 children• HUT, CSM, ECG, BP• 19 (6161%) alternative

diagnosis– 9 VVS

– 7 LQTS

– 1 psychogenic

– 2 CSH

– 2 bradycardia

Pediatrician: Akhtar 2002Neurologist: Smith et al, 2002

Epilepsy

40% 40% treatment resistant seizurestreatment resistant seizures cardiovascular cardiovascular

Assessment- Assessment- Poor recall, Amnesia LOC, No collateralPoor recall, Amnesia LOC, No collateral

History, Exam, ECG, Orthostatic BP, CSM

Syncope, Not Syncope

Cardiac, Neurally Mediated, Inconclusive

Risk Stratification

The history history is critical :•Eliminating other diagnoses•Discriminating among causes of syncope•Finding reversible c auses•Establishing the prognosis•Expediting accurate treatment

•FallsFalls

TIATIA

•EpilepsyEpilepsy

30% patientsReferred TIA clinicReviewed 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 yrs 77% female.

monoparesis/dysasthesia (12), hemiparesis/dysasthesia (7), isolated facial droop (4).

Median 5 min median 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 stroke

D J Ryan, S Christensen, J F Meaney, A Fagan, R A Kenny, J A Harbison

all acute strokes prospective screen presyncope or 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 stroke

D 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 stroke

D 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.