Amnesia for Loss of Consciousness in Carotid Sinus Syndrome

The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map

BACKGROUND

We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults.

METHODS

Design: scoping review and evidence map.

DATA SOURCES

Medline and Embase.

ELIGIBILITY CRITERIA

all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis.

RESULTS

Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning).

CONCLUSION

Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.

Cardiovascular disease and the risk of incident falls and mortality among adults aged ≥ 65 years presenting to the emergency department: a cohort study from national registry data in Denmark

BACKGROUND

Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality.

METHODS

A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined.

RESULTS

Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history.

CONCLUSION

In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Trauma and syncope: looking beyond the injury

Background

42% of the population experience syncope by the age of 70, accounting for up to 6% of hospital admissions that frequently present as falls. The etiologies of some falls are benign, and others, such as cardiac syncope, are associated with a greater mortality and must be identified.

Methods

This review article aims to bridge the literature gap by providing a comprehensive practice review and critical summary of the current syncope guidance relating to the trauma patient.

Results

The National Institute for Health and Care Excellence, the American College of Cardiology, and European Society of Cardiology published syncope risk stratification guidance. The inclusion of certain high-risk features represented in all three guidelines suggests their significance to identify cardiac syncope including heart failure, abnormal vital signs, syncope during exercise with little to no prodrome, family history of sudden cardiac death, and ECG abnormalities. Of 11 syncope risk stratification scoring systems based on these guidelines, only 2 are externally validated in the emergency department, neither of which are validated for major trauma use. Adherence to thorough history-taking, examination, orthostatic blood pressure recording, and an ECG can diagnose the cause of syncope in up to 50% of patients. ECG findings are 95% to 98% sensitive in the detection of serious adverse outcomes after cardiac syncope and should form part of a standardized syncope trauma assessment. Routine blood testing in trauma is often performed despite evidence that it is neither useful nor cost effective, where the screening of cardiac enzymes and D-dimer rarely influences management.

Discussion

In the absence of a gold-standard clinical test to identify the cause of a syncopal episode, standardized syncope guidelines as described in this review could be incorporated into trauma protocols to analyze high-risk etiologies, improve diagnostic accuracy, reduce unnecessary investigations, and develop an effective and safer management strategy.

An atypical presentation of orthostatic hypotension and falls in an older adult

Introduction

Falls are a significant cause of morbidity and mortality in older adults. Orthostatic hypotension (OH) is very common in this cohort of patients and is a significant risk for falls and associated injuries. We present the case of an 89-year-old female who fell at home, witnessed by her husband. OH was identified during the clinical assessment and considered to be the predominant contributing factor, although the clinical presentation was not associated with classical symptoms.

Case presentation

The patient lost balance while turning away from the kitchen sink; she noted some instability due to a complaint of generalised weakness in both of her legs. No acute medical illness or traumatic injury was identified. A comprehensive history was obtained that identified multiple intrinsic and extrinsic risk factors for falling. The cardiovascular examination was unremarkable except for OH, with a pronounced reduction in systolic blood pressure of 34 mmHg at the three-minute interval and which reproduced some generalised weaknesses in the patient's legs and slight instability. Although classical OH symptoms were not identified, this was considered to be the predominant factor contributing to the fall. A series of recommendations was made to primary and community-based care teams based upon a rapid holistic review; this included a recommendation to review the patient's dual antihypertensive therapy.

Conclusion

It is widely known that OH is a significant risk factor for falls, but asymptomatic or atypical presentations can make diagnosis challenging. Using the correct technique to measure a lying and standing blood pressure, as defined by the Royal College of Physicians, is crucial for accurate diagnosis and subsequent management. Ambulance clinicians are ideally placed to undertake this quick and non-invasive assessment to identify OH in patients that have fallen.

Syncope and the aging patient: Navigating the challenges

Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.

Prognosis of Syncope With Head Injury: a Tertiary Center Perspective

Aim: Head injury is the most common trauma occurring in syncope. We aimed to assess whether syncope as cause of head-trauma affects short-and long-term prognosis.

Methods: From a database retrospective analysis of 97,014 individuals attending Emergency Department (ED), we selected data of patients with traumatic head injury including age, gender, injury mechanism, brain imaging, multiple traumas, bone fracture, intracranial bleeding, and mortality. Mean follow-up was 6.4 ± 1.8 years. Outcome data were obtained from a digital national population register. The study population included 3,470 ED head injury patients: 117 of them (50.0 ± 23.6 years, 42.7% men) reported syncope as cause of head trauma and 3,315 (32.2 ± 21.1 years, 68.5% men) without syncope preceding head trauma.

Results: Thirty-day mortality was low and similar in traumatic head injury with or without syncope. One year and long-term all-cause mortality were both significantly higher in syncopal vs. non-syncopal traumatic head injury (11.1 vs. 2.8% and 32 vs. 10.2%, respectively; both p < 0.001). In adjusted logistic regression analysis, death between 121st-day and 1 year in patients with head-trauma was associated with male gender [odds ratio (OR): 6.48; 95% CI: 2.59–16.25], advancing age (per year) (OR 1.09; 95% CI 1.07–1.11), Glasgow Coma Scale < 13 (OR: 6.18; 95% CI:1.68–22.8), bone fracture (OR 4.72; 95% CI 2.13–10.5), and syncope (OR 3.70; 95% CI: 1;48–9.31). In multivariable Cox regression analysis, syncope was one of the strongest independent predictors of long-term all-cause death (hazard ratio: 1.95; 95% CI 1.37–2.78).

Conclusion: In patients with head trauma, history of syncope preceding injury does not increase 30-day all-cause mortality but portends increased 1 year and long-term mortality.

The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis

BACKGROUND

Orthostatic hypotension (OH) is associated with increased risk of falls, cognitive impairment and death, as well as a reduced quality of life. Although it is presumed to be common in older people, estimates of its prevalence vary widely. This study aims to address this by pooling the results of epidemiological studies.

METHODS

MEDLINE, EMBASE, PubMed, Web of Science, and ProQuest were searched. Studies were included if participants were more than 60 years, were set within the community or within long-term care and diagnosis was based on a postural drop in systolic blood pressure (BP) ≥20 mmHg or diastolic BP ≥10 mmHg. Data were extracted independently by two reviewers. Random and quality effects models were used for pooled analysis.

RESULTS

Of 23,090 identified records, 20 studies were included for community-dwelling older people (n = 24,967) and six were included for older people in long-term settings (n = 2,694). There was substantial variation in methods used to identify OH with differing supine rest duration, frequency and timing of standing BP, measurement device, use of standing and tilt-tables and interpretation of the diagnostic drop in BP. The pooled prevalence of OH in community-dwelling older people was 22.2% (95% CI = 17, 28) and 23.9% (95% CI = 18.2, 30.1) in long-term settings. There was significant heterogeneity in both pooled results (I2 > 90%).

CONCLUSIONS

OH is very common, affecting one in five community-dwelling older people and almost one in four older people in long-term care. There is great variability in methods used to identify OH.

The prevalence of unexplained falls and syncope in older adults presenting to an Irish urban emergency department

AIM

There is growing evidence of an overlap between unexplained falls and syncope in older adults. Our aim was to examine the prevalence and associated resource utilization of these conditions in an urban emergency department (ED).

PATIENTS AND METHODS

A single-centre, prospective, observational study was carried out over a 6-month period. Consecutive patients older than 50 years who presented to the ED because of a fall, collapse or syncope were included. Univariate analysis of demographic data is presented as percentages, mean (SD), 95% confidence intervals (CIs) and medians (interquartile range). Logistic regression modelling was used to examine the association between falls and resource utilization.

RESULTS

A total of 561 patients fulfilled the inclusion criteria during the study period. Unexplained fallers accounted for 14.3% (n=80; 95% CI: 13.3-15.3) and syncope for 12.7% (n=71; 95% CI: 11.7-13.6) of all fall presentations. Overall, 50% (n=282; 95% CI: 48.20-52.34) of patients required admission to hospital. Patients with syncope [odds ratio (OR)=2.48, 95% CI: 1.45-4.23], and unexplained falls (OR=2.36, 95% CI: 1.37-4.08) were more likely to require admission than those with an explained falls. Unexplained fallers were nearly five times more likely to suffer recurrent falls (OR=4.97, 95% CI: 2.89-8.56).

CONCLUSION

One in four older fallers presenting to ED have symptoms suggestive of syncope or an unexplained fall. There are significant biological consequences of recurrent falls including greater rates of cognitive decline, gait and mobility disturbances, depression and frailty. Recognition that syncope can present as an unexplained fall in older adults is important to ensure that appropriate early modifiable interventions are initiated.

Risk of post-discharge fall-related injuries among adult patients with syncope: A nationwide cohort study

Background

Syncope could be related to high risk of falls and injury in adults, but documentation is sparse. We examined the association between syncope and subsequent fall-related injuries in a nationwide cohort.

Methods

By cross-linkage of nationwide registers, all residents ≥18 years with a first-time diagnosis of syncope were identified between 1997–2012. Syncope patients were matched 1:1 with individuals from the general population. The absolute one-year risk of fall-related injuries, defined as fractures and traumatic head injuries requiring hospitalization, was calculated using Aalen-Johansen estimator. Ratios of the absolute one-year risk of fall-related injuries (ARR) were assessed by absolute risk regression analysis.

Results

We identified 125,763 patients with syncope: median age 65 years (interquartile range 46–78). At one year, follow-up was complete for 99.8% where a total of 8394 (6.7%) patients sustained a fall-related injury requiring hospitalization, of which 1606 (19.1%) suffered hip fracture. In the reference group, 4049 (3.2%) persons had a fall-related injury. The one-year ARR of a fall-related injury was 1.79 (95% confidence interval 1.72–1.87, P<0.001) in patients with syncope compared with the reference group; however, increased ARR was not exclusively in older patients. Factors independently associated with increased ARR of fall-related injuries in the syncope population were: injury in past 12 months, 2.39 (2.26–2.53, P<0.001), injury in relation to the syncope episode, 1.62 (1.49–1.77, P<0.001), and depression, 1.37 (1.30–1.45, P<0.001)

Conclusion

Patients with syncope were at 80% increased risk of severe fall-related injuries within the year following discharge. Notably, increased risk was not exclusively in older patients.

A prospective study of the association between orthostatic hypotension and falls: definition matters

Background

falls are a common cause of morbidity and mortality in older people. Orthostatic hypotension (OH) is considered an important risk factor for falls, but longitudinal studies have failed to show a clear association. This disparity may be because conventional methods of measuring blood pressure (BP) changes are too imprecise and/or the diagnostic criteria for OH are inappropriate. Over recent years, beat-to-beat BP monitoring techniques, which enabled accurate measurement of vasodepression, have become widely used and in 2011 the American Academy of Neurology produced revised diagnostic criteria for OH.

Objective

to use beat-to-beat monitoring to compare the prevalence of OH using the standard and revised diagnostic criteria and to establish which criteria are most valuable in predicting future falls.

Design

two hundred and ninety-seven community-dwelling older people aged ≥65 years underwent assessment. Active stand using digital photoplethysmography was used to record postural change in BP. One hundred participants were asked to complete prospective weekly falls diaries for 12 months.

Results

OH, defined according to the revised American Academy of Neurology diagnostic criteria, affected 25% of participants and was an independent predictor of falls (odds ratio 10.299, 95% confidence interval [95% CI]: 1.703-61.43, P = 0.011) and time to first fall (hazard ratio 3.017, 95% CI: 1.291-7.050, P = 0.011). OH, defined according to standard criteria, affected 80% of the population and was not associated with falls.

Conclusion

OH, defined according to 2011 criteria, is associated with falls and time to first fall. These findings indicate that beat-to-beat monitoring and the 2011 criteria for OH are valuable in the clinical assessment of older fallers.

Clinical differences among the elderly admitted to the emergency department for accidental or unexplained falls and syncope

It is difficult to distinguish unexplained falls (UFs) from accidental falls (AFs) or syncope in older people. This study was designed to compare patients referred to the emergency department (ED) for AFs, UFs or syncope. Data from a longitudinal study on adverse drug events diagnosed at the ED (ANCESTRAL-ED) in older people were analyzed in order to select cases of AF, syncope, or UF. A total of 724 patients (median age: 81.0 [65-105] years, 66.3% female) were consecutively admitted to the ED (403 AF, 210 syncope, and 111 UF). The number of psychotropic drugs was the only significant difference in patients with AF versus those with UF (odds ratio [OR] 1.44; 95% confidence interval 1.17-1.77). When comparing AF with syncope, female gender, musculoskeletal diseases, dementia, and systolic blood pressure >110 mmHg emerged as significantly associated with AF (OR 0.40 [0.27-0.58], 0.40 [0.24-0.68], 0.35 [0.14-0.82], and 0.31 [0.20-0.49], respectively), while valvulopathy and the number of antihypertensive drugs were significantly related to syncope (OR 2.51 [1.07-5.90] and 1.24 [1.07-1.44], respectively). Upon comparison of UF and syncope, the number of central nervous system drugs, female gender, musculoskeletal diseases, and SBP >110 mmHg were associated with UF (OR 0.65 [0.50-0.84], 0.52 [0.30-0.89], 0.40 [0.20-0.77], and 0.26 [0.13-0.55]), respectively. These results indicate specific differences, in terms of demographics, medical/pharmacological history, and vital signs, among older patients admitted to the ED for AF and syncope. UF was associated with higher use of psychotropic drugs than AF. Our findings could be helpful in supporting a proper diagnostic process when evaluating older patients after a fall.

Impaired Orthostatic Blood Pressure Recovery Is Associated with Unexplained and Injurious Falls

OBJECTIVES

Cardiovascular disorders are recognized as important modifiable risk factors for falls. However, the association between falls and orthostatic hypotension (OH) remains ambivalent, particularly because of poor measurement methods of previous studies. The goal was to determine for the first time to what extent OH (and variants) are risk factors for incident falls, unexplained falls (UF), injurious falls (IF) and syncope using dynamic blood pressure (BP) measurements in a population study.

DESIGN

Nationally representative longitudinal cohort study-The Irish Longitudinal Study on Ageing (TILDA)-wave 1 (2009-2011) with 2-year follow-up at wave 2 (2012-2013).

SETTING

Community-dwelling adults.

PARTICIPANTS

Four thousand one hundred twenty-seven participants were randomly sampled from the population of older adults aged ≥50 years resident in Ireland.

MEASUREMENTS

Continuous BP recordings measured during active stands were analyzed. OH and variants (initial OH and impaired orthostatic BP stabilization OH(40)) were defined using dynamic BP measurements. Associations with the number of falls, UF, IF, and syncope reported 2 years later were assessed using negative binomial and modified Poisson regression as appropriate.

RESULTS

Participants had a mean age of 61.5 (8.2) years (54.2% female). OH(40) was associated with increased relative risk of UF (RR: 1.52 95% CI: 1.03-2.26). OH was associated with all-cause falls (IRR: 1.40 95% CI: 1.01-1.96), UF(RR: 1.81 95% CI: 1.06-3.09), and IF(RR: 1.58 95% CI: 1.12-2.24). IOH was not associated with any outcome.

CONCLUSION

With the exception of initial orthostatic hypotension, beat-to-beat measures of impaired orthostatic BP recovery (delayed recovery OH (40) or sustained orthostatic hypotension OH) are independent risk factors for future falls, unexplained falls, and injurious falls.

Droxidopa and Reduced Falls in a Trial of Parkinson Disease Patients With Neurogenic Orthostatic Hypotension

OBJECTIVES

Droxidopa is a prodrug of norepinephrine indicated for the treatment of orthostatic dizziness, lightheadedness, or the "feeling that you are about to black out" in adult patients with symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure including Parkinson disease (PD). The objective of this study was to compare fall rates in PD patients with symptomatic neurogenic orthostatic hypotension randomized to droxidopa or placebo.

METHODS

Study NOH306 was a 10-week, phase 3, randomized, placebo-controlled, double-blind trial of droxidopa in PD patients with symptomatic neurogenic orthostatic hypotension that included assessments of falls as a key secondary end point. In this report, the principal analysis consisted of a comparison of the rate of patient-reported falls from randomization to end of study in droxidopa versus placebo groups.

RESULTS

A total of 225 patients were randomized; 222 patients were included in the safety analyses, and 197 patients provided efficacy data and were included in the falls analyses. The 92 droxidopa patients reported 308 falls, and the 105 placebo patients reported 908 falls. In the droxidopa group, the fall rate was 0.4 falls per patient-week; in the placebo group, the rate was 1.05 falls per patient-week (prespecified Wilcoxon rank sum P = 0.704; post hoc Poisson-inverse Gaussian test P = 0.014), yielding a relative risk reduction of 77% using the Poisson-inverse Gaussian model. Fall-related injuries occurred in 16.7% of droxidopa-treated patients and 26.9% of placebo-treated patients.

CONCLUSIONS

Treatment with droxidopa appears to reduce falls in PD patients with symptomatic neurogenic orthostatic hypotension, but this finding must be confirmed.

Stroke and Falls-Clash of the Two Titans in Geriatrics

Both stroke and falls are common conditions affecting the older adult. Despite stroke being considered a well-established major risk factor for falls, there remains no evidence for effective prevention strategies for falls specifically for stroke survivors. Previous observational studies evaluating falls risk factors in stroke have mainly been uncontrolled and found similar risk factors for stroke populations compared to general older populations. Specific risk factors, however, are likely to play a greater role in stroke survivors including unilateral weakness, hemisensory or visual neglect, impaired coordination, visual field defects, perceptual difficulties and cognitive issues. In addition, individuals with stroke are also more likely to have other associated risk factors for falls including diabetes, falls risk increasing drugs, atrial fibrillation, and other cardiovascular risk factors. While anticoagulation is associated with increased risk of intracranial bleeding after a fall, the risk of suffering a further stroke due to atrial fibrillation outweigh the risk of bleeding from a recurrent fall. Similarly, while blood pressure lowering medications may be linked to orthostatic hypotension which in turn increases the risk of falls, the benefit of good blood pressure control in terms of secondary stroke prevention outweighs the risk of falls. Until better evidence is available, the suggested management approach should then be based on local resources, and published evidence for fall prevention. Multicomponent exercise and individually tailored multifactorial interventions should still be considered as published evidence evaluating the above have included stroke patients in their study population.

Managing Syncope in the Elderly: The Not So Simple Faint in Aging Patients

Providing care to the elderly patient with syncope poses problems that are unusual in their complexity. The differential diagnosis is broad, and sorting through it is made more difficult by the relative lack of symptoms surrounding the faint. Indeed, distinguishing faints from falls is often problematic. Many elderly patients are frail and are at risk of trauma if they should have an unprotected faint or fall to the ground. However, not all elderly patients are frail, and definitions of frailty vary. Providing accurate, effective, and appropriate care for the frail elderly patient who faints may require a multidisciplinary approach.

Safety and tolerability of Tilt Testing and Carotid Sinus Massage in the octogenarians

OBJECTIVE

to evaluate the safety and tolerability of Tilt Testing (TT) and Carotid Sinus Massage (CSM) in octogenarians with unexplained syncope.

METHODS

patients consecutively referred for transient loss of consciousness to the 'Syncope Units' of three hospitals were enrolled. TT and CSM were performed according to the European Society of Cardiology guidelines on syncope. Complications were evaluated in each group. An early interruption of TT was defined as 'intolerance' and considered as a non-diagnostic response.

RESULTS

one thousand four hundred and one patients were enrolled (mean age 72 ± 16 years, male 40.8%). Six hundred and ninety-four patients (49.5%) were 80 years old or older (mean age 83 ± 3 years) and 707 (50.5%) were younger (mean age 60 ± 17 years). Complications after TT occurred in 4.5% of older patients and in 2.1% of the younger ones (P = 0.01). All complications were 'minor/moderate', as prolonged hypotension, observed in ∼3% of patients ≥80 years. Major complications such as sustained ventricular tachycardia, ventricular fibrillation, asystole requiring cardiac massage, transient ischaemic attack, stroke and death were not observed in any patient. The presence of orthostatic hypotension and the mean number of syncopal episodes were predictors of TT complications. Intolerance was reported in 2.4% of older patients and 1% of the younger ones (P = 0.08), mainly due to orthostatic intolerance. No complications occurred after CSM.

CONCLUSIONS

TT and CSM appear to be safe and well tolerated in octogenarians, who should not be excluded by age from the diagnostic work-up of syncope.

Postural blood pressure electrocardiographic changes are associated with falls in older people

OBJECTIVES

To determine the magnitude of postural blood pressure change, differences in ECG between fallers and non-fallers were measured. Postural blood pressure change is associated with symptoms of dizziness, presyncope, and syncope.

METHODS

In this cross-sectional study were included participants from The Malaysian Falls Assessment and Intervention Trial: fallers, aged 65 years or older with two or more falls or one injurious fall in 12 months, from a teaching hospital; and non-fallers, aged 65 years and older found through word-of-mouth and advertising. Noninvasive beat-to-beat blood pressure was measured at 10 min supine rest and 3 min standing. The maximal drop in systolic and diastolic pressure was calculated from a 12-lead ECG interpreted by a cardiologist. Basic demographics, medical history, and symptoms of dizziness, presyncope, and syncope were recorded for all patients.

RESULTS

We recruited 155 fallers and 112 non-fallers. Fallers had a significantly longer PR interval (179 ± 32 vs. 168 ± 27 ms, p = 0.013) and a longer corrected QT interval (449 ± 41 vs. 443 ± 39 msec, p = 0.008), and larger change in SBP (28 ± 14 vs. 19 ± 9 mmHg, p < 0.001) with posture change. SBP drop of ≥30mmHg associated with recurrent and injurious falls [odds ratio [95 % confidence interval] = 7.61 (3.18-18.21)]. The changes remained significant after adjustment for symptoms of dizziness, presyncope and syncope.

INTERPRETATION

Older individuals with recurrent and injurious falls have significantly longer PR and QT intervals and larger SBP reduction with posture change as compared to non-fallers, and these are not explained by the presence of dizziness, presyncope, or syncope. SBP cut-off of ≥30mmHg considered for postural measurements using continuous BP monitors, the significance of this value needs to be evaluated.

The Association of Cardiovascular Disorders and Falls: A Systematic Review

OBJECTIVE

Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care.

DESIGN

Systematic review.

DATA SOURCES

Medline and Embase.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale.

RESULTS

Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities.

CONCLUSION

Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions.

AF is associated with self-reported syncope and falls in a general population cohort

BACKGROUND

syncope is an important, but underestimated clinical problem in older persons. It is often overlooked in clinical practice or mistaken for falls. Atrial fibrillation (AF) is the most common cardiac arrhythmia, but little evidence exists regarding the association between AF, falls and syncope in the general population.

METHODS

cross-sectional analyses within a population sample of people aged 50+, taken from The Irish Longitudinal Study on Ageing. Ten-minute electrocardiogram recordings (n = 4,885) were analysed to detect AF. Syncope (self-reported faints or blackouts) and falls in the past year, co-morbidities, health measures and medications were gathered through computer-aided personal interviews. Multivariable logistic regression was performed to study associations between AF, falls and syncope.

RESULTS

mean age was 62 years (range: 50-91), 54% were female. Prevalence of AF was 3%, increasing to 8% in participants aged 75+. Of participants, 5% (n = 223) reported syncope and 20% (n = 972) reported falls. After adjustment for confounders, AF was significantly associated with faints and blackouts (odds ratio (OR) 2.0 [95% confidence interval (CI) 1.0-3.9]). After stratification by age category, we found that this association was strongest and only significant in participants aged 50-64 years (OR 4.4 [1.5-12.6]). Stratified for age group, AF was significantly associated with falls in participants aged 65-74 years (OR 2.0 [1.0-4.1]).

CONCLUSIONS

adults aged 50+ with self-reported syncope and adults aged 65-74 years with falls are twice as likely to have AF at physical examination. These associations are independent of stroke, cardiovascular and psychotropic drugs and other confounders. Further longitudinal studies are needed to explore this association and potential causality further.

The Role of the Syncope Management Unit

Syncope is a common symptom, experienced by 15% of persons less than 18 years old and up to 23% of elderly nursing home residents, so it is important to consider optimizing strategies for the management of these patients. The strategy selected will inevitably differ from place to place. However, an organized structure offers more cost-effective care. This article discusses possible health care delivery models for syncope management and reviews the current status of the organization of syncope care, to show the value of a multidisciplinary approach to the organized management of patients with syncope.

Initial Clinical Evaluation

The initial evaluation of patients with transient loss of consciousness (LOC) comprises a detailed medical history, physical examination, and 12-lead electrocardiogram. Because there are many causes of syncopal and nonsyncopal LOC, an adequate method of taking the clinical history, which is the cornerstone of diagnosing patients with transient LOC, should be used.

Self-reported cardiovascular conditions are associated with falls and syncope in community-dwelling older adults

BACKGROUND

with increasing age, causes of syncope are more often of cardiac origin. Syncope in older persons is often mistaken for falls. Data regarding the association between specific cardiovascular conditions, falls and syncope are limited.

METHODS

cross-sectional analyses within a population sample aged 50+ (n = 8,173). Syncope and falls in the past year, cardiovascular conditions and co-variates were gathered through personal interviews. Associations between cardiovascular conditions and (recurrent) falls and syncope were studied through multivariable logistic regression.

RESULTS

mean age was 64 years (range: 51-105); 54% was female. Four per cent reported syncope, 19% falls and 23% cardiovascular morbidity. Abnormal heart rhythm was associated with falls (odds ratio (OR) 1.3 [95% confidence interval (CI) 1.0-1.5]), syncope (OR 1.6 [1.2-2.3]) and recurrent syncope (OR 2.2 [1.3-3.6]). Heart murmur was associated with falls (OR 1.4 [1.1-1.8]), recurrent falls (OR 1.5 [1.0-2.0]) and syncope (OR 1.9 [1.3-2.7]). Angina was associated with recurrent falls (OR 1.4 [1.0-1.9]), syncope (OR 1.8 [1.2-2.6]) and recurrent syncope (OR 2.7 [1.6-4.6]). Heart failure was associated with recurrent falls (OR 1.9 [1.0-3.4]) and myocardial infarction with syncope (OR 1.5 [1.0-2.3]).

CONCLUSION

self-reported cardiovascular conditions are associated with falls and syncope in a general population cohort. This warrants additional cardiovascular evaluation in older patients with unexplained falls and syncope.

The different clinical presentations of vasovagal syncope

For some decades, after the introduction of the head-up tilt test into clinical practice, the clinical presentation of vasovagal syncope (VVS) has been classified as typical (or classical) and atypical (or non-classical). Some clinical features and recent data suggest that even unexplained falls and syncope during sleeping hours may be possible clinical presentations of VVS. In recent studies, tilt testing and carotid sinus massage by means of the 'method of symptoms' were performed in one group of patients with unexplained falls and in another group with unexplained syncope (presence of prodromal symptoms). Overall, tilt testing and carotid sinus massage displayed a high positivity rate in the group of patients with unexplained falls (about 60%), which was similar to that of the unexplained syncope group. These new data seem to indicate that some unexplained falls could be cases of atypical VVS/carotid sinus syncope with retrograde amnesia. Some clinical features suggest that syncope during sleeping hours is a form of VVS with a different clinical presentation: high prevalence of autonomic prodromes, of diurnal episodes of typical VVS and specific phobias, and of positive tilt testing with severe cardioinhibition.

Recent syncope and unexplained falls are associated with poor cognitive performance

OBJECTIVE

To compare cognitive performance in participants with and without syncope and unexplained falls in a large population representative sample aged 50 years or older.

METHODS

Participants of the Irish longitudinal study on ageing (TILDA) were studied. Participants with a history of syncope and/or unexplained falls in the past 12 months were compared with those with no reported events. Cognitive performance was measured using the Montreal cognitive assessment (MoCA) score. Multivariate linear regression analysis controlling for potential confounders was performed to compare cognitive function by syncope and falls status.

RESULTS

Five thousand eight hundred and forty-six participants were analysed, median age 62 years (inter-quartile range=14), and 54% were female. Five hundred and forty-nine (9.4%) had a syncopal event and/or an unexplained fall in past 12 months. One hundred and two (1.8%) subjects had two-plus syncopal events in the same period. There was a significant association between syncope/falls history and lower MoCA score, following adjustment for all confounders (B=-0.4; -0.69, -0.11; P=0.006). Higher syncope burden was also associated with lower performance; however, this was largely explained by confounders. There was no age interaction with these findings.

CONCLUSION

Participants who experienced syncope and/or non-accidental falls in the previous year have poor global cognitive performance compared with case-controls. There was no effect of age on our results. Further investigation of the association between syncope burden, unexplained falls and cognitive decline is required to establish a relationship between these disorders.

Falls risk factors: assessment and management to prevent falls and fractures

Falls and fragility fractures are common, dangerous, and important public health challenges. They are best understood as geriatric syndromes with close relation to frailty and other aging-related health problems. They are associated with many risk factors, in all health domains - physical, psychological, social, and environmental. At a population level, the challenge is to improve the health and well-being of all older people to reduce the incidence of falls. At a clinical level, the challenge is to assess the individual risk factors and apply evidence-based individually tailored, multifactorial interventions. The most powerful component is strength-and-balance exercise training.

Differential diagnosis between 'unexplained' fall and syncopal fall: a difficult or impossible task

Falls may be accidental (because of slipping, tripping or environmental hazards) or 'unexplained', when there is no apparent cause. Syncope is a transient loss of consciousness (LOC) and, if it occurs when the person is in the upright position, may lead to a fall. The differential diagnosis between 'unexplained' fall and syncopal fall can be difficult, if not impossible, because many patients have retrograde amnesia after syncope, that is they do not remember their prodromal symptoms. Based on the results of many randomized studies, the international guidelines on falls suggest multifactorial assessment and multifactorial treatment. Unfortunately, however, the vast majority of studies have been carried out on a mixed population of patients who have suffered accidental and 'unexplained' falls. As 'unexplained' falls account for a minority of cases, we really do not know the efficacy of multifactorial treatment in patients with this type of fall. Very recent data seem to prove that many older patients with 'unexplained' falls are actually affected by reflex syncope with retrograde amnesia, as they experience LOC during tilt testing or carotid sinus massage. Although these data make an important contribution to our knowledge of the mechanism of 'unexplained' falls, the therapeutic problems remain largely unsolved.

[Experience with the use of an implantable loop recorder in a series of older people with falls and suspected arrhythmic syncopes]

OBJECTIVE

To review our experience on using an implantable loop recorder (ILR) in patients with recurrent falls, when an arrhythmogenic cause is suspected.

MATERIAL AND METHODS

This is a retrospective, observational study of patients with repetitive unexplained falls, suspected syncope, or electrocardiographic abnormalities. All of them had been evaluated by a cardiologist, who decided to implant a loop recorder (ILR) for an accurate diagnosis.

RESULTS

A total of 13 patients received an ILR. The average falls rate for the sample was 3.3. The mean age was 78 years, and 46% were female, with a mean follow-up period of 24 months. During this time, three patients did not suffer from a new fall. An arrhythmogenic diagnosis was obtained in 5 patients: bradycardia was identified in 4 cases, and tachycardia in one of them. The symptoms did not coincide with a documented arrhythmia in the rest of the patients.

CONCLUSION

ILR is a helpful tool to establish an arrhythmogenic cause of unexplained and recurrent falls, in this selected sample of older adults.

Clinical aspects and diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls

OBJECTIVE

To evaluate the diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls compared to those with a syncope etiologically unexplained after initial evaluation.

METHODS

It is an observational study, comparing 298 patients with unexplained fall with 989 patients with unexplained syncope. Each patient underwent supine and upright blood pressure measurement, tilt testing (TT) and carotid sinus massage (CSM).

RESULTS

Patients with unexplained falls were older (75.3 ± 11.1 vs. 63.2 ± 19.2 years, p < 0.001), were more frequently hypertensive (66.1 vs. 47.2 %, p < 0.001) and more frequently prescribed antihypertensive drugs (62.4 vs. 48.7 %, p < 0.001) or benzodiazepines (15.7 vs. 10.6 %, p = 0.01), and in a greater proportion they experienced major traumatic injuries (77.5 vs. 29.6 %, p < 0.001) as a consequence of falls. The TT was less frequently positive in patients with unexplained falls (36 vs. 51.3 %, p < 0.001), whereas a Carotid Sinus Syndrome as suggested by CSM had a similar prevalence in the two groups (14.3 vs. 10.5 %, p = 0.074). Overall, either TT or CSM were positive in 61 % of patients with unexplained falls, and in 64 % of those with syncope (p = 0.346). After matching by age 298 patients with falls (75.3 ± 11.1 years) and 298 patients with unexplained syncope (75.4 ± 11.1 years), we found that the positivity prevalence of TT and CSM were similar in the two groups.

CONCLUSIONS

The positivity prevalence of TT and CSM in patients with unexplained falls compared to patients with unexplained syncope is similar. Given its high diagnostic relevance, the neuroautonomic evaluation should be routinely performed in older patients with unexplained falls.

Syncope in the Elderly

A rapid change in ageing demographic is taking place worldwide such that healthcare professionals are increasingly treating old and very old patients. Syncope in the elderly is a challenging presentation that is under-recognised, particularly in the acute care setting. The reason for this is that presentation in the older person may be atypical: patients are less likely to have a prodrome, may have amnesia for loss of consciousness and events are frequently unwitnessed. The older patient thus may present with a fall rather than transient loss of consciousness. There is an increased susceptibility to syncope with advancing age attributed to age-related physiological impairments in heart rate and blood pressure, and alterations in cerebral blood flow. Multi-morbidity and polypharmacy in these complex patients increases susceptibility to syncope. Cardiac causes and more than one possible cause are also common. Syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs. In view of this, prompt assessment and early targeted intervention are recommended. The purpose of this article is to update the reader regarding the presentation and management of syncope in this rapidly changing demographic.

At the heart of the arterial baroreflex: a physiological basis for a new classification of carotid sinus hypersensitivity

The aim of this review is to provide an update of the current knowledge of the physiological mechanisms underlying reflex syncope. Carotid sinus syncope will be used as the classical example of an autonomic reflex with relatively well-established afferent, central and efferent pathways. These pathways, as well as the pathophysiology of carotid sinus hypersensitivity (CSH) and the haemodynamic effects of cardiac standstill and vasodilatation will be discussed. We will demonstrate that continuous recordings of arterial pressure provide a better understanding of the cardiovascular mechanisms mediating arterial hypotension and cerebral hypoperfusion in patients with reflex syncope. Finally we will demonstrate that the current criteria to diagnose CSH are too lenient and that the conventional classification of carotid sinus syncope as cardioinhibitory, mixed and vasodepressor subtypes should be revised because isolated cardioinhibitory CSH (asystole without a fall in arterial pressure) does not occur. Instead, we suggest that all patients with CSH should be thought of as being 'mixed', between cardioinhibition and vasodepression. The proposed stricter set of criteria for CSH should be evaluated in future studies.

Feasibility and accuracy of fall reports in persons with dementia: a prospective observational study

BACKGROUND

The feasibility, test-retest reliability, and accuracy of different fall recording methods have not been studied in older persons with dementia.

METHODS

This was a prospective observational study, nested within a randomized controlled trial on motor training, in which 110 participants were monitored for falls over 12 months. Seven methods of fall recording were compared: face-to-face interviews; phone interviews: weekly for three months, monthly for 9 months, a final interview after 12 months; prospective calendar method; interviews with a proxy and the general practitioner (GP). Summing the count of falls and removing duplicate reporting of the same fall was found to provide the best approximation of the actual number of falls and was chosen as the criterion-standard.

RESULTS

The combination of calendar method and phone interviews showed the highest accuracy (74% of falls, 93% of fallers). As a single measure, weekly phone calls were superior to calendars or proxy-report. Monthly phone calls recorded only half the falls that were picked up by weekly calls (p = 0.002) and were inferior to the calendars (p<0.001) and proxy-report (p = 0.015). GPs knew of only 14% of falls and 19% of fallers. In addition, 49% of subjects who documented a fall prospectively did not recall a fall after 12 months.

CONCLUSION

The combination of fall calendars with regular telephone interviews can be recommended for persons with mild to moderate stage dementia. If feasible, recall periods should be as short as one week; additional information by care-givers increases accuracy of reports. Retrospective recall of falling with long recall periods is not recommended.

The prevalence of Neurally Mediated Syncope in older patients presenting with unexplained falls

AIMS

To determine the prevalence and clinical significance of carotid sinus syndrome (CSS) and vasovagal syncope (VVS), the two common types of Neurally Mediated Syncope (NMS), in a cohort of older patients with unexplained falls.

METHODS

Patients presenting with unexplained and accidental falls were identified from 200 consecutive admissions of falls in patients aged 65 years and older admitted to the Rapid Assessment Medical Unit (RAMU) in a teaching hospital. A sample of unexplained and accidental fallers underwent carotid sinus massage (CSM) and tilt table testing (TTT) as per a standardised protocol. Baseline characteristics, clinical variables and the prevalence of NMS were compared between the two groups.

RESULTS

Falls were unexplained in 26% of patients. The prevalence of NMS was 24% (5/21) among patients with unexplained falls who underwent assessment for NMS, whereas it was nil (0/17) in patients with accidental falls (P=0.050). The prevalence of previous falls was significantly higher in patients with unexplained falls (P=0.0025), but all other baseline characteristics were similar between the two groups.

CONCLUSION

Falls are unexplained in a significant number of older patients presenting to acute hospitals. The assessment of unexplained fallers for NMS is clinically important as this may be aetiologically related in nearly a quarter of these patients.

Carotid sinus syndrome is common in very elderly patients undergoing tilt table testing and carotid sinus massage because of syncope or unexplained falls

BACKGROUND AND AIMS

Although the incidence of falls and syncope increase with age, the underlying mechanisms are not fully understood, particularly in very old patients. We report diagnostic outcomes of tilt table and carotid sinus massage (TT/CSM) testing in a population of older old subjects (82% over 80 years of age) referred for TT/CSM from a falls clinic for assessment of syncope or unexplained falls.

METHODS

Prospective observational study between January 1, 2001 and January 1, 2005 involving 290 consecutive subjects undergoing TT/CSM testing according to European Society of Cardiology guidelines for the diagnosis and management of syncope.

RESULTS

Combination of TT/CSM provided a positive result in 62% of subjects, and was significantly more likely to be positive in subjects over the age of 80 (68% vs 50%, p=0.001). Carotid sinus syndrome (CSS) was the most common diagnosis, and was significantly more common in subjects over 80 (48% vs 34%, p=0.022) particularly due to a higher incidence of mixed CSS (16% vs 7%, p=0.023). There was no significant difference in the diagnosis of subjects referred due to falls and those reporting syncope (p=0.93). No cardiovascular or neurological adverse events occurred.

CONCLUSIONS

In our cohort of very elderly patients, the diagnostic accuracy of tilt testing and carotid sinus massage was high and adverse incidents absent when testing was indicated by a geriatrician experienced in the assessment of falls and syncope. We advocate the use of TT/CSM testing as part of a comprehensive falls/syncope assessment for the diagnostic evaluation of older patients presenting with unexplained falls and/or syncope in whom structured assessment has not identified a cause for their symptoms.