Skip to main content
SpringerLink
Log in

Syncope

  • Reference work entry
  • First Online:
Geriatric Medicine

  • 357 Accesses

Abstract

The prevalence of syncope increases with advancing age and is associated with significant morbidity and mortality. Age per se should not be considered a barrier to the assessment and treatment of syncope. On the contrary, older patients with syncope require an early and detailed investigation and management.

The diagnosis within this population can be complex due to atypical presentations, amnesia for events, absence of witnesses, and overlap with other clinical presentations as falls. Falls unrelated to specific medical or accidental conditions are defined unexplained and may underlie a syncopal mechanism.

A comprehensive assessment of comorbid conditions and drug regimen is necessary. A standardized guidelines-based approach on neurally mediated syncope, through active standing test, Carotid Sinus Massage and Tilt Testing, is well tolerated in older patients. Advances in cardiac monitoring devices have increased the diagnostic yield for cardiac syncope. Treatment of syncope ranges from simple conservative measures to permanent cardiac pacing.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39:1883–1948.

    Google Scholar 

  2. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of Syncope. N Engl J Med. 2002;347:878–85.

    Article  PubMed  Google Scholar 

  3. Ruwald MH, Hansen ML, Lamberts M, et al. The relation between age, sex, comorbidity, and pharmacotherapy and the risk of syncope: a Danish nationwide study. Europace. 2012;14:1506–14.

    Article  PubMed  Google Scholar 

  4. Olde Nordkamp LAR, van Dijk N, Ganzeboom KS, et al. Syncope prevalence in the ED compared to that in the general practice and population: a strong selection process. Am J Emerg Med. 2009;27:271–9.

    Article  PubMed  Google Scholar 

  5. Del Rosso A, Alboni P, Brignole M, et al. Relation of clinical presentation of syncope to the age of patients. Am J Cardiol. 2005;96:1431–5.

    Article  PubMed  Google Scholar 

  6. 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.

    Article  PubMed  Google Scholar 

  7. Van Lieshout JJ, Wieling W, Karemaker JM, et al. Syncope, cerebral perfusion, and oxygenation. J Appl Physiol. 2003;94:833–48.

    Article  PubMed  Google Scholar 

  8. Brignole M, Moya A, de Lange FJ, et al. Practical instructions for the 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39:e43–80.

    Article  PubMed  Google Scholar 

  9. Kenny RA. Syncope in the elderly: diagnosis, evaluation, and treatment. J Cardiovasc Electrophysiol. 2003;14:S74–7.

    Article  PubMed  Google Scholar 

  10. van Wijnen VK, Finucane C, Harms MPM, et al. Noninvasive beat-to-beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages. J Intern Med. 2017;282:468–83.

    Article  PubMed  Google Scholar 

  11. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 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.

    Article  Google Scholar 

  13. O’Dwyer C, Bennett K, Langan Y, et al. Amnesia for loss of consciousness is common in vasovagal syncope. Europace. 2011;13:1040–5.

    Article  PubMed  Google Scholar 

  14. Tan MP, Parry SW. Vasovagal syncope in the older patient. J Am Coll Cardiol. 2008;51:599–606.

    Article  PubMed  Google Scholar 

  15. Wieling W, Krediet CT, Solari D, et al. At the heart of the arterial baroreflex: a physiological basis for a new classification of carotid sinus hypersensitivity. J Intern Med. 2013;273:345–58.

    Article  CAS  PubMed  Google Scholar 

  16. 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.

    Article  PubMed  Google Scholar 

  17. Kerr SR, Pearce MS, Brayne C, et al. Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls. Arch Intern Med. 2006;166:515–20.

    Article  PubMed  Google Scholar 

  18. Sutton R. Carotid sinus syndrome: progress in understanding and management. Global Cardiol Sci Pract. 2014;2:1–8.

    Google Scholar 

  19. 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.

    Article  PubMed  Google Scholar 

  20. 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.

    PubMed  PubMed Central  Google Scholar 

  21. Mussi C, Ungar A, Salvioli G, et al. Evaluation of guidelines in syncope study 2 group. 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.

    Article  PubMed  Google Scholar 

  22. Wieling W, Krediet CT, van Dijk N, et al. Initial orthostatic hypotension: review of a forgotten condition. Clin Sci. 2007;112:157–65.

    Article  Google Scholar 

  23. 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.

    Article  PubMed  Google Scholar 

  24. Ricci F, De Caterina R, Fedorowski A. Orthostatic hypotension: epidemiology, prognosis, and treatment. J Am CollCardiol. 2015;66:848–60.

    Article  Google Scholar 

  25. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264:1567–82.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Marrison VK, Fletcher A, Parry SW. The older patient with syncope: practicalities and controversies. Int J Cardiol. 2012;155:9–13.

    Article  CAS  PubMed  Google Scholar 

  27. Brignole M, Menozzi C, Bartoletti A, et al. A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J. 2006;27:76–82.

    Article  PubMed  Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. de Ruiter SC, Wold JFH, Germans T, et al. Multiple causes of syncope in the elderly: diagnostic outcomes of a Dutch multidisciplinary syncope pathway. Europace. 2017;0:1–6.

    Google Scholar 

  30. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Solari D, Maggi R, Oddone D, et al. Assessment of the vasodepressor reflex in carotid sinus syndrome. Circ Arrhythm Electrophysiol. 2014;7:505–10.

    Article  PubMed  Google Scholar 

  32. Lopes R, Gonçalves A, Campos J, et al. The role of pacemaker in hypersensitive carotid sinus syndrome. Europace. 2011;13:572–5.

    Article  PubMed  Google Scholar 

  33. Davies AG, Kenny RA. Neurological complication following carotid sinus massage. Am J Cardiol. 1998;81:1256–7.

    Article  CAS  PubMed  Google Scholar 

  34. Grossman SA, Van Epp S, Arnold R, et al. The value of cardiac enzymes in elderly patients presenting to the emergency department with syncope. J Gerontol A Biol Sci Med Sci. 2003;58:1055–9.

    Article  PubMed  Google Scholar 

  35. Chiu DT, Shapiro NI, Sun BC, et al. Are echocardiography, telemetry, ambulatory electrocardiography monitoring and cardiac enzymes in emergency department patients presenting with syncope useful tests? A preliminary investigation. J Emerg Med. 2014;47:113–8.

    Article  PubMed  Google Scholar 

  36. Goyal N, Donnino MW, Vachhani R, et al. The utility of head computed tomography in the emergency department evaluation of syncope. Intern Emerg Med. 2006;1:148–50.

    Article  PubMed  Google Scholar 

  37. Sun BC, Costantino G, Barbic F, et al. Priorities for emergency department syncope research. Ann Emerg Med. 2014;64:649–55.

    Article  PubMed  Google Scholar 

  38. D’Angelo RN, Pickett CC. Diagnostic yield of device interrogation in the evaluation of syncope in an elderly population. Int J Cardiol. 2017;236:164–7.

    Article  PubMed  Google Scholar 

  39. Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J. https://doi.org/10.1093/eurheartj/ehu255.

  40. 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.

    Article  PubMed  Google Scholar 

  41. 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.

    Article  PubMed  Google Scholar 

  42. 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.

    Article  CAS  PubMed  Google Scholar 

  43. Ungar A, Ceccofiglio A, Pescini F, et al. Syncope and epilepsy coexist in ‘possible’ and ‘drug-resistant’ epilepsy (Overlap between Epilepsy and Syncope Study – OESYS). BMC Neurol. 2017;17:45.

    Article  PubMed  PubMed Central  Google Scholar 

  44. 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.

    Article  PubMed  Google Scholar 

  45. Ungar A, Rivasi G, Rafanelli M, et al. Safety and tolerability of tilt testing and carotid sinus massage in the octogenarians. Age Ageing. 2016;45:242–8.

    Article  PubMed  Google Scholar 

  46. Low PA, Denq JC, Opfer-Gehrking TL, et al. Effect of age and gender on sudomotor and cardiovagal function and blood pressure response to tilt in normal subjects. Muscle Nerve. 1997;20:1561–8.

    Article  CAS  PubMed  Google Scholar 

  47. Benezet-Mazuecos J, Ibanez B, Rubio JM, et al. Utility of in-hospital cardiac remote telemetry in patients with unexplained syncope. Europace. 2007;9:1196–201.

    Article  PubMed  Google Scholar 

  48. Pürerfellner H, Sanders P, Pokushalov E, et al. Miniaturized reveal LINQ insertable cardiac monitoring system: first-in-human experience. Heart Rhythm. 2015;12:1113–9.

    Article  PubMed  Google Scholar 

  49. 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.

    Article  PubMed  Google Scholar 

  50. William B, Mancia G, Spiering W, et al. ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J. 2018;33:3021–104.

    Article  Google Scholar 

  51. Solari D, Tesi F, Unterhuber M, et al. Stop vasodepressor drugs in reflex syncope: a randomised controlled trial. Heart. 2017;103:449–55.

    Article  PubMed  Google Scholar 

  52. Rivasi G, Brignole M, Rafanelli M. et al. Blood pressure management in hypertensive patients with syncope: how to balance hypotensive and cardiovascular risk. J Hypertens 2020;38:2356–2362.

    Google Scholar 

  53. 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.

    Article  PubMed  Google Scholar 

  54. Brignole M, Arabia F, Ammirati F, et al. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace. 2016;18:1427–33.

    Article  PubMed  Google Scholar 

  55. 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.

    Article  CAS  PubMed  Google Scholar 

  56. 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.

    Article  PubMed  Google Scholar 

  57. Alboni P, Coppola P, Stucci N, et al. Differential diagnosis between ‘unexplained’ fall and syncopal fall: a difficult or impossible task. J Cardiovasc Med (Hagerstown). 2015;16:82–9.

    Article  PubMed  Google Scholar 

  58. Finucane C, O’Connell MDL, Donoghue O, et al. Impaired orthostatic blood pressure recovery is associated with unexplained and injurious falls. J Am Geriatr Soc. 2017;65:474–82.

    Article  PubMed  Google Scholar 

  59. 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.

    Article  PubMed  Google Scholar 

  60. 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.

    Article  CAS  PubMed  Google Scholar 

  61. 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.

    Article  PubMed  Google Scholar 

  62. Allan LM, Ballard CG, Rowan EN, et al. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS One. 2009;4:e5521.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Ungar A, Mussi C, Ceccofiglio A, et al. Etiology of Syncope and unexplained falls in elderly adults with dementia: syncope and dementia (SYD) study. J Am Geriatr Soc. 2016;64:1567–73.

    Article  PubMed  Google Scholar 

  64. Testa G, Ceccofiglio A, Mussi C, et al. Hypotensive drugs and Syncope due to orthostatic hypotension in older adults with dementia (syncope and dementia study). J Am Geriatr Soc. 2018;66:1532–7.

    Article  PubMed  Google Scholar 

  65. Mossello E, Ceccofiglio A, Rafanelli M, et al. Differential diagnosis of unexplained falls in dementia: results of “Syncope & Dementia” registry. Eur J Intern Med. 2018;50:41–6.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Syncope Unit, University of Florence and Azienda Ospedaliero-Universitaria Careggi Florence, Florence, Italy

    Andrea Ungar, Martina Rafanelli, Giulia Rivasi & Irene Marozzi

Authors
  1. Andrea Ungar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Martina Rafanelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giulia Rivasi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Irene Marozzi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrea Ungar .

Editor information

Editors and Affiliations

  1. California Association of Long Term Care Medicine, Newbury Park, CA, USA

    Michael R. Wasserman

  2. Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA

    Debra Bakerjian

  3. Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA

    Sunny Linnebur

  4. Division of Geriatrics, SUNY Upstate Medical University, Syracuse, NY, USA

    Sharon Brangman

  5. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    Matteo Cesari

  6. Section of Geriatric Medicine, Division of Internal Medicine, Department of Medicine, Cedars-Sinai, Beverly Hills, CA, USA

    Sonja Rosen

Section Editor information

  1. California Association of Long Term Care Medicine, Newbury Park, California, USA

    Michael R. Wasserman M.D., CMD

  2. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    Matteo Cesari MD, PhD

  3. Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

    Matteo Cesari MD, PhD

Rights and permissions

Reprints and permissions

Copyright information

© 2024 Springer Nature Switzerland AG

About this entry

Check for updates. Verify currency and authenticity via CrossMark

Cite this entry

Ungar, A., Rafanelli, M., Rivasi, G., Marozzi, I. (2024). Syncope. In: Wasserman, M.R., Bakerjian, D., Linnebur, S., Brangman, S., Cesari, M., Rosen, S. (eds) Geriatric Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-74720-6_29

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-74720-6_29

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-74719-0

  • Online ISBN: 978-3-030-74720-6

  • eBook Packages: MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation