Advertisement

Syncope and Unexplained Falls in the Elderly

  • Martina Rafanelli
  • Michele Brignole
  • Rose Anne KennyEmail author
Chapter

Abstract

The prevalence of syncope increases with advancing age and is associated with significant morbidity and mortality. The diagnosis within this population can be complex due to atypical presentations, amnesia for events, absence of witnesses, and the overlap with other clinical presentations such as falls. Falls, which are not related to specific medical or accidental conditions, are defined as unexplained and may underlie a syncopal mechanism.

A comprehensive assessment of comorbid conditions and drug regimes coupled with standardized guidelines-based approaches to neurally mediated syncope, including active standing test, carotid sinus massage, and tilt testing, is recommended and these tests are generally well tolerated in older patients. Advances in cardiac monitoring devices have further enhanced the diagnostic yield for cardiac syncope. The treatment of syncope ranges from simple conservative measures to medications and permanent cardiac pacing.

Age per se should not be considered a barrier to assessment and treatment of syncope. On the contrary, given the much higher prevalence of cardiac causes of syncope, it could be argued that older patients with syncope and/or unexplained falls require an early and detailed investigation and management.

Keywords

Orthostatic Hypotension Multiple System Atrophy Retrograde Amnesia Cerebral Hypoperfusion Tilt Test 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009;30:2631–71.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Savage DD, Corwin L, McGee DL, et al. Epidemiologic features of isolated syncope: the Framingham Study. Stroke. 1985;16:626–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347:878–85.CrossRefPubMedGoogle Scholar
  4. 4.
    Brignole M, Menozzi C, Bartoletti A, et al. A new management of syncope: prospective systematic guideline-based evaluation of patient referred urgently to general hospitals. Eur Heart J. 2006;27:76–82.CrossRefPubMedGoogle Scholar
  5. 5.
    Alshekhlee A, Shen WK, Mackall J, et al. Incidence and mortality rates of syncope in the United States. Am J Med. 2009;122:181–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Sun BC, Emond JA, Camargo CA. Direct medical costs of syncope related hospitalizations in the United States. Am J Cardiol. 2005;95:668–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health. 2003;57:740–4.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Malasana G, Brignole M, Daccarett M, et al. The prevalence and cost of the faint and fall problem in the State of Utah. PACE. 2011;34:278–83.CrossRefPubMedGoogle Scholar
  9. 9.
    Kenny RA, O’Shea D. Falls and syncope in elderly patients. Clin Geriatr Med. 2002;18:XIII–XIV.Google Scholar
  10. 10.
    Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–58.CrossRefPubMedGoogle Scholar
  11. 11.
    Tinetti ME. Preventing falls in elderly persons. N Engl J Med. 2003;348:41–9.CrossRefGoogle Scholar
  12. 12.
    Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337:1279–84.CrossRefPubMedGoogle Scholar
  13. 13.
    Marottoli RA, Berkman LF, Cooney LM. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40:861–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Jørstad EC, Hauer K, Becker C, et al. Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 2005;53:501–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Masud T, Morris RO. Epidemiology of falls. Age Ageing. 2001;30:3–7.Google Scholar
  16. 16.
    Carey BJ, Potter JF. Cardiovascular causes of falls. Age Ageing. 2001;30:19–24.CrossRefPubMedGoogle Scholar
  17. 17.
    Kenny RA, Richardson DA, Steen N, et al. Carotid sinus syndrome: a modifiable risk factor for non accidental falls in older adults (SAFE PACE). J Am Coll Cardiol. 2001;38:1491–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Chiara M, Gianluigi G, Pasquale A, et al. Unexplained falls are frequent in patients with fall-related injury admitted to orthopaedic wards: the UFO Study (unexplained falls in older patients). Curr Gerontol Geriatr Res. 2013. doi:http://dx.doi.org/ 10.1155/2013/928603.
  19. 19.
    Jansen S, Bhangu J, de Rooij S, Daams J, Kenny RA, van der Velde N. The Association of Cardiovascular Disorders and falls: A Systematic Review. J Am Med Dir Assoc. 2016 Mar 1;17(3):193–9.Google Scholar
  20. 20.
    Van Lieshout JJ, Wieling W, Karemaker JM, et al. Syncope, cerebral perfusion, and oxygenation. J Appl Physiol. 2003;94:833–48.CrossRefPubMedGoogle Scholar
  21. 21.
    Willie CK, Tzeng YC, Fisher JA, Ainslie PN. Integrative regulation of human brain blood flow. J Physiol. 2014 Mar 1;592(5):841–59.Google Scholar
  22. 22.
    Serrador JM, Sorond FA, Vyas M, et al. Cerebral pressure-flow relations in hypertensive elderly humans: transfer gain in different frequency domains. J Appl Physiol. 2005;98:151–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Kenny RA. Syncope in the elderly: diagnosis, evaluation, and treatment. J Cardiovasc Electrophysiol. 2003;14:S74–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Carey BJ, Panerai RB, Potter JF. Effect of aging on dynamic cerebral autoregulation during head-up tilt. Stroke. 2003;34:1871–5.CrossRefPubMedGoogle Scholar
  25. 25.
    Giese AE, Li V, McKnite S, et al. Impact of age and blood pressure on the lower arterial pressure limit for maintenance of consciousness during passive upright posture in healthy vasovagal fainters: preliminary observations. Europace. 2004;6:457–62.CrossRefPubMedGoogle Scholar
  26. 26.
    Del Rosso A, Alboni P, Brignole M, et al. Relation of clinical presentation of syncope to the age of patients. Am J Cardiol. 2006;96:1431–5.CrossRefGoogle Scholar
  27. 27.
    Galizia G, Abete P, Mussi C, et al. Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly. J Am Geriatric Soc. 2009;57:18–23.CrossRefGoogle Scholar
  28. 28.
    Tan MP, Parry SW. Vasovagal syncope in the older patient. J Am Coll Cardiol. 2008;51:599–606.CrossRefPubMedGoogle Scholar
  29. 29.
    O’Dwyer C, Bennett K, Langan Y, et al. Amnesia for loss of consciousness is common in vasovagal syncope. Europace. 2011;13:1040–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21:69–72.CrossRefPubMedGoogle Scholar
  31. 31.
    Rafanelli M, Morrione A, Landi A, et al. Neuroautonomic evaluation of patients with unexplained syncope: incidence of complex neurally mediated diagnoses in the elderly. Clin Interv Aging. 2014;9:333–8.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Finucane C, O’Connell MD, Fan CW, Savva G, Soraghan CJ, Nolan H, Cronin H, Kenny RA. Age Related Normative Changes in Phasic Orthostatic Blood Pressure in a Large Population Study: findings from The Irish Longitudinal Study on Ageing (TILDA). Circulation 2014. Nov 11;130(20):1780–9.Google Scholar
  33. 33.
    Mussi C, Ungar A, Salvioli G, Evaluation of Guidelines in Syncope Study 2 Group, et al. Orthostatic hypotension as cause of syncope in patients older than 65 years admitted to emergency departments for transient loss of consciousness. J Gerontol A Biol Sci Med Sci. 2009;64:801–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Wieling W, Krediet CT, van Dijk N, et al. Initial orthostatic hypotension: review of a forgotten condition. Clin Sci. 2007;112:157–65.CrossRefPubMedGoogle Scholar
  35. 35.
    Robinovitch SN, Feldman F, Yang Y, et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet. 2013;381:47–54.CrossRefPubMedGoogle Scholar
  36. 36.
    Finucane C, O’Connell M, Donoghue O, Richardson K, Savva G, Kenny RA. Impaired Orthostatic Blood Pressure Recovery is Associated with Unexplained and Injurious Falls. JAGS (IN PRESS) 0769-C1-Jun16.R1.Google Scholar
  37. 37.
    Bhangu JS, King-Kallimanis B, Cunningham C, Kenny RA. The relationship between syncope, depression and anti-depressant use in olders adults. Age Ageing. 2014;43(4):502–9.Google Scholar
  38. 38.
    Marrison VK, Fletcher A, Parry SW. The older patient with syncope: practicalities and controversies. Int J Cardiol. 2012;155:9–13.CrossRefPubMedGoogle Scholar
  39. 39.
    Shaw BH, Claydon VE. The relationship between orthostatic hypotension and falling in older adults. Clin Auton Res. 2014;24:3–13.CrossRefPubMedGoogle Scholar
  40. 40.
    Wieling W, Thijs RD, van Dijk N, et al. Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain. 2009;132:2630–42.CrossRefPubMedGoogle Scholar
  41. 41.
    Hohler AD, Zuzuarregui JR, Katz DI, et al. Differences in motor and cognitive function in patients with Parkinson’s disease with and without orthostatic hypotension. Int J Neurosci. 2012;122:233–6.CrossRefPubMedGoogle Scholar
  42. 42.
    Cordeiro RC, Jardim JR, Perracini MR, et al. Factors associated with functional balance and mobility among elderly diabetic outpatients. Arq Bras Endocrinol Metabol. 2009;53:834–43.CrossRefPubMedGoogle Scholar
  43. 43.
    Kennelly SP, Lawlor BA, Kenny RA. Blood pressure and the risk for dementia: a double edged sword. Ageing Res Rev. 2009;8:61–70.CrossRefPubMedGoogle Scholar
  44. 44.
    Mehrabian S, Duron E, Labouree F, et al. Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci. 2010;299:45–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Frewen J, Savva GM, Boyle G, et al. Cognitive performance in orthostatic hypotension: findings from a nationally representative sample. J Am Geriatr Soc. 2014;62:117–22.CrossRefPubMedGoogle Scholar
  46. 46.
    Frewen J, Finucane C, Savva GM, et al. Orthostatic hypotension is associated with lower cognitive performance in adults aged 50 plus with supine hypertension. J Gerontol A Biol Sci Med Sci. 2014;69:878–85.CrossRefPubMedGoogle Scholar
  47. 47.
    Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons.Google Scholar
  48. 48.
    Maggi R, Menozzi C, Brignole M, et al. Cardioinhibitory carotid sinus hypersensitivity predicts an asystolic mechanism of spontaneous neurally mediated syncope. Europace. 2007;9:563–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Sutton R. Carotid sinus syndrome: progress in understanding and management. Glob Cardiol Sci Pract. 2014;18.Google Scholar
  50. 50.
    Brignole M, Auricchio A, Baron-Esquivias G, et al. ESC Guidelines on cardiac pacing and cardiac resynchronization therapy The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15:1070–118.CrossRefPubMedGoogle Scholar
  51. 51.
    Solari D, Maggi R, Oddone D, et al. Clinical context and outcome of carotid sinus syndrome diagnosed by means of the “method of symptoms”. Europace. 2014;16:928–34.CrossRefPubMedGoogle Scholar
  52. 52.
    Kerr SRJ, Pearce MS, Brayne C, Davis RJ, Kenny RA. Carotid Sinus Hypersensitivity in Asymptoamtic Older Persons: Implications for Diagnosis of Syncope and Falls. Arch ntern Med. 2006. March 13;166(5):515–520.Google Scholar
  53. 53.
    Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37:1921–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Del Rosso A, Ungar A, Maggi R, et al. Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to general hospital: the EGSYS score. Heart. 2008;94:1620–6.CrossRefPubMedGoogle Scholar
  55. 55.
    Ungar A, Mussi C, Del Rosso A, et al. Diagnosis and characteristics of syncope in older patients referred to geriatric departments. J Am Geriatr Soc. 2006;54:1531–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Parry SW, Richardson DA, O’Shea D, et al. Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential. Heart. 2000;83:22–3.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Solari D, Maggi R, Oddone D, et al. Assessment of the vasodepressor reflex in carotid sinus syndrome. Circ Arrhythm Electrophysiol. 2014;7:505–10.CrossRefPubMedGoogle Scholar
  58. 58.
    Lopes R, Gonçalves A, Campos J, et al. The role of pacemaker in hypersensitive carotid sinus syndrome. Europace. 2011;13:572–5.CrossRefPubMedGoogle Scholar
  59. 59.
    Davies AG, Kenny RA. Neurological complication following carotid sinus massage. Am J Cardiol. 1998;81:1256–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Del Rosso A, Ungar A, Bartoli P, et al. Usefulness and safety of shortened head-up tilt testing potentiated with sublingual glyceryl trinitrate in older patients with recurrent unexplained syncope. J Am Geriatr Soc. 2002;50:1324–8.CrossRefPubMedGoogle Scholar
  61. 61.
    Del Rosso A, Bartoletti A, Bartoli P, et al. Methodology of head-up tilt testing with sublingual nitroglycerin in unexplained syncope. Am J Cardiol. 2000;85:1007–11.CrossRefPubMedGoogle Scholar
  62. 62.
    Forleo C, Guida P, Iacoviello M, et al. Head-up tilt testing for diagnosing vasovagal syncope: a meta-analysis. Int J Cardiol. 2013;168:27–35.CrossRefPubMedGoogle Scholar
  63. 63.
    Ungar A, Sgobino P, Russo V, et al. Diagnosis of neurally mediated syncope at initial evaluation and with tilt table testing compared with that revealed by prolonged ECG monitoring. An analysis from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Heart. 2013;99:1825–31.CrossRefPubMedGoogle Scholar
  64. 64.
    Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J. 2014;35(33):2211–2. doi: 10.1093/eurheartj/ehu255.CrossRefPubMedGoogle Scholar
  65. 65.
    Brignole M, Menozzi C, Moya A, et al. Pacemaker therapy in patients with neurally mediated syncope and documented asystole. Third international study on syncope of unknown etiology (ISSUE-3): a randomized trial. Circulation. 2012;125:2566–71.CrossRefPubMedGoogle Scholar
  66. 66.
    Brignole M, Donateo P, Tomaino M, et al. Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative. An analysis from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Circ Arrhythm Electrophysiol. 2014;7:10–6.CrossRefPubMedGoogle Scholar
  67. 67.
    Rafanelli M, Ruffolo E, Chisciotti VM, et al. Clinical aspects and diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls. Aging Clin Exp Res. 2014;26:33–7.CrossRefPubMedGoogle Scholar
  68. 68.
    Brignole M, Vardas P, Hoffman E, et al. Indications for the use of diagnostic implantable and external ECG loop recorders. Europace. 2009;11:671–87.CrossRefPubMedGoogle Scholar
  69. 69.
    Brignole M, Menozzi C, Maggi R, Solano A, Donateo P, Bottoni N, et al. The usage and diagnostic yield of implantable loop-recorder in detection of the mechanism of syncope and in guiding effective antiarrhythmic therapy in older people. Europace. 2005;7:273–9.CrossRefPubMedGoogle Scholar
  70. 70.
    Roberto M, Martina R, Alice C, et al. Additional diagnostic value of implantable loop recorder in patients with initial diagnosis of real or apparent transient loss of consciousness of uncertain origin. Europace. 2014;16:1226–30.CrossRefPubMedGoogle Scholar
  71. 71.
    Brignole M, Ammirati F, Arabia F, et al. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J. 2015;36:1529–35.CrossRefPubMedGoogle Scholar
  72. 72.
    Metzler M, Duerr S, Granata R, et al. Neurogenic orthostatic hypotension: pathophysiology, evaluation and management. J Neurol. 2013;260:2212–9.CrossRefPubMedGoogle Scholar
  73. 73.
    Singer W, Sandroni P, Opfer-Gehrking TL, Suarez GA, Klein CM, Hines S, O’Brien PC, Slezak J, Low PA. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol. 2006;63:513–8.CrossRefPubMedGoogle Scholar
  74. 74.
    Kaufmann H, Freeman R, Biaggioni I, et al. Droxidopa for neurogenic orthostatic hypotension A randomized, placebo-controlled, phase 3 trial. Neurology. 2014;83:328–35.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Martina Rafanelli
    • 1
  • Michele Brignole
    • 2
  • Rose Anne Kenny
    • 3
    Email author
  1. 1.Careggi HospitalFlorenceItaly
  2. 2.Arrhythmology Centre, Department of CardiologyOspedali del TigullioLavagnaItaly
  3. 3.School of MedicineTrinity College Dublin, Health Sciences Institute, St James’s HospitalDublin 8Ireland

Personalised recommendations