SYNCOPE

IN ELDERLY

IGP SUKA ARYANA

Geriatric Consultant of Sanglah Teaching
Hospital
Udayana University

SYNCOPE
SYNCOPE AND DIZZNESS
SYNCOPE ITSELF IS NOT A DIAGNOSIS.
CARDIOVASCULAR DISORDERS CAUSE MOST
SYNCOPE AND PRESYNCOPE IN THE ELDERLY.
THE INCIDENCE OF SYNCOPE INCREASES
DRAMATICALLY WITH ADVANCING AGE

DEFINITION
THE PATHOGNOMONIC FEATURE OF SYNCOPE IS A
SUDDEN LOSS OF CONSCIOUSNESS AND
POSTURAL TONE RESULTING FROM A DECREASE
IN CEREBRAL BLOOD FLOW.
THE LOSS OF CONSCIOUSNESS IS BRIEF, AND
RECOVERY IS RAPID AND SPONTANEOUS.

DIAGNOSIS

ANAMNESIS
PHYSICAL EXM
CHEST X RAY
ECG
LABORATORY TEST
OTHERS

PATIENT HISTORY

OTHER SYNCOPE EVENTS,

GENERAL MEDICAL PROBLEMS,

DETAILS OF ACTIVITIES ENGAGED IN JUST BEFORE THE

SYNCOPAL EVENT, AND ANY ASSOCIATED SYMPTOMS.
CHEST PAIN, PALPITATIONS, AND DYSPNEA ON EXERTION.

AN ASSESSMENT OF CARDIAC RISK SHOULD INCLUDE A

FAMILY HISTORY OF SUDDEN OR UNEXPLAINED DEATH.

MEDICATION LIST SHOULD BE CAREFULLY REVIEWED.

PATIENT HISTORY

NONCARDIAC CAUSES (NEURAL MEDIATED) COUGHING,

URINATION /DEFECATION, OR EATING.

EMOTIONALLY STRESSFUL EVENT OCCURRED JUST BEFORE

THE SYNCOPE, A VASOVAGAL CAUSE FOR THE SYNCOPE
SHOULD BE CONSIDERED. ASSOCIATED WARM FEELING,
DIAPHORESIS, OR FLUSHING AS WELL AS
GASTROINTESTINAL SYMPTOMS SUCH AS NAUSEA SUPPORT
THIS DIAGNOSIS.

CARDIAC EXAMINATION
ASSESSMENT OF THE PATIENT'S CAROTID PULSE.
DELAYED UPSTROKE OR LOW VOLUME IS
CONSISTENT WITH AORTIC STENOSIS.
PALPATION FOR A DISPLACED POINT OF MAXIMAL
IMPULSE AND EXTRA SOUNDS ON AUSCULTATION
RAISE THE INDEX OF SUSPICION FOR
CARDIOMYOPATHY.
AUSCULTATION MAY PROVIDE EVIDENCE FOR
VALVULAR HEART DISEASE.
ALL PATIENTS SHOULD ALSO UNDERGO A
RESTING ELECTROCARDIOGRAM (ECG).

TABLE HELPFUL HISTORY, PHYSICAL EXAMINATION, & ECG FINDINGS.

VARIABLE

DESCRIPTION

HISTORY
RISKFACTORS

DIABETES,CARDIACDISEASE,PROLONGEDBEDREST,
PSYCHIATRICHISTORY

REVIEW

MEDICATIONLIST

PROVOKINGSITUATION

EMOTIONALSTRESS,FREQUENTOCCURRENCE

TEMPORAL

ACUTEONSET,SPONTANEOUSRECOVERY,POSTICTALCONFUSION

PRIORACTIVITY

COUGH,URINATION,DEFECATION,SWALLOWING,MEALINGESTION

PRIORMOVEMENT

STANDING,HEADTURN

GENERALSYMPTOMS

WARMTH,NAUSEA,FLUSHING

CARDIACSYMPTOMS

CHESTPAIN,PALPITATIONS,DYSPNEA

PHYSICAL EXAMINATION
PULSE

DELAYEDUPSTROKE,LOWAMPLITUDE

CARDIAC

ARRHYTHMIA,DISPLACEDPMI,MURMURS,S3

CAROTID

BRUITS,CAROTIDMASSAGEA

NEUROLOGIC

FOCALDEFICITS

OTHEREXAMINATIONS

ORTHOSTATICBLOODPRESSUREMEASUREMENTS,STOOLOCCULT
BLOODTESTING

ECG
ACUTECHANGESORQ
WAVES

ACUTEORPREVIOUSMYOCARDIALINFARCTION

ABNORMALRHYTHM

TACHY/BRADYCARDIA,SICKSINUSSYNDROME

ABNORMALINTERVAL

QTPROLONGATION

ABNORMALCONDUCTION

HEARTBLOCK,BUNDLEBRANCHBLOCK

PERFORMEDONLYWHENRECENTSTROKE,MYOCARDIALINFARCTION,ANDBRUITSAREABSENT.

LABORATORY TESTING
HEMATOCRIT, ELECTROLYTES, AND RENAL
FUNCTION TESTS ARE USEFUL IF ANEMIA OR
VOLUME DEPLETION IS SUSPECTED.
CARDIAC ENZYMES SHOULD BE RESERVED FOR
SITUATIONS IN WHICH THE PATIENT HISTORY
SUPPORTS A CARDIAC CAUSE OF SYNCOPE.

SPECIAL TESTS

ELECTROCARDIOGRAPHY
ECHOCARDIOGRAPHY
AMBULATORY ECG (HOLTER) MONITORING
TILT-TABLE TESTING FOR PATIENTS SUSPECTED
OF HAVING NONCARDIAC (NEURALLY MEDIATED)
SYNCOPE
ELECTROPHYSIOLOGICAL STUDIES
NEUROLOGICAL TESTING: EEG, BRAIN IMAGING
(MRI, CT SCAN)
PSYCHIATRIC EXAMINATION

DIFFERENTIAL DIAGNOSIS
DIZZINESS/
CONDITION

SYNCOPE

PRESYNCOPE

LOSSOFCONSCIOUSNESS

YES

ABSENT

ONSETOFEVENT

ABRUPT

PROTRACTED

FALLS

YES

POSSIBLE

PRECIPITATEDBYSTRESSFUL
EVENT

YES

POSSIBLE

AURABEFOREEVENT

POSSIBLE

POSSIBLE

BLADDER/BOWELINCONTINENCE

POSSIBLE

ABSENT

DISORIENTATIONPOSTEVENT

YES

ABSENT

CAUSEOFSYNCOPE
SITUATIONAL
COUGH,TOILETING,SWALLOWING,POSTPRANDIAL
VASOVAGAL
MOVEMENTINDUCED
ORTHOSTATICHYPOTENSION
SUBCLAVIANSTEAL
CAROTIDSINUSHYPERSENSITIVITY
PSYCHIATRIC
ANXIETY/PERSONALITYDISORDERS
SEIZURE
COMPLEX-PARTIALEPILEPSY
STROKEWITHSECONDARYSEIZURE
CARDIOVASCULAR
MYOCARDIALINFARCTION,CARDIOMYOPATHY
SINUSNODE/PACEMAKERMALFUNCTION,HEARTBLOCK
VENTRICULAR/SUPRAVENTRICULARTACHYCARDIA,
TORSADES
AORTICSTENOSIS/DISSECTION,PULMONARYEMBOLISM,
TAMPONADE

LOC,LOSSOFCONSCIOUSNESS.

CAUSE/CHARACTERISTICS
VAGALACTIVITY
ASSOCIATEDONLYWITH
ACTIVITY
WARMTH,NAUSEA
CEREBRALPERFUSIONDEFICIT
STANDING,MEDICATIONS
HEADTURN
NECKPRESSURE/HEADTURN
VARIOUSCAUSES
FREQUENT,NOINJURY,NO
TRUELOC
NEURONALDISCHARGE
INCONTINENCE,POSTICTAL
PHASE
ADDITIONALFOCALDEFICITS
DECREASEDCARDIACOUTPUT
ORGANICHEARTDISEASE
BRADYARRHYTHMIAINDUCED
TACHYARRHYTHMIAINDUCED
OUTFLOWOBSTRUCTION

TREATMENT

TREATMENT FOR PATIENTS WITH SYNCOPE SHOULD FOCUS

ON THE SUSPECTED UNDERLYING CAUSE

CARDIAC SYNCOPE

CARDIAC ISCHEMIA SHOULD BE TREATED APPROPRIATELY.

TREATMENT OPTIONS FOR ARRHYTHMIAS MAY INCLUDE

PHARMACOLOGICAL THERAPIES OR PACEMAKER INSERTION.

PATIENTS WITH COMPROMISED VENTRICULAR FUNCTION

HAVE BEEN SHOWN TO BENEFIT FROM AUTOMATIC
IMPLANTABLE CARDIOVERTER DEFIBRILLATORS.

CAROTID SINUS HYPERSENSITIVITY AVOID EXACERBATING

FACTORS, INCLUDING TIGHT COLLARS OR RAPID NECK
MOVEMENT.

POSTPRANDIAL HYPOTENSION AVOID LARGE MEALS AS

WELL AS PHYSICAL ACTIVITY AFTER EATING.

ORTHOSTATIC HYPOTENSION TRAINED TO RISE FROM

SUPINE AND SEATED POSITIONS SLOWLY, AVOID
PROLONGED STANDING, INCREASE FLUID AND SALT INTAKE,
ORAL INTAKE AND REVIEW MEDICATIONS,

COMPRESSION

STOCKINGS AND ISOMETRIC LEG EXERCISES

 VASOVAGAL EVENTS ARE BEST TREATED BY

AVOIDANCE OF THE TRIGGER, IF POSSIBLE. IF
SYMPTOMS OCCUR DURING TOILETING, SAFETY
DEVICES SUCH AS A BATHTUB SAFETY BAR AND A
TOILET SEAT WITH ARMRESTS CAN BE
RECOMMENDED.
PATIENTS REFERRED FOR TILT-TABLE TESTING
HAVE BEEN SHOWN TO BENEFIT FROM A SIMPLE
PROCEDURE OF LEG CROSSING AND MUSCLE
TENSING FOR 30 S AT THE ONSET OF SYMPTOMS.

 INDIVIDUALS WITH SYNCOPE THAT REMAINS

UNEXPLAINED BY ALL INVESTIGATIONS MAY HAVE
A PSYCHIATRIC CONDITION.
ELDERLY INDIVIDUALS WITH DIZZINESS OR
SYNCOPE OF ANY CAUSE ARE AT RISK FOR
TRAUMATIC INJURY.
FALLS REPRESENT A SOURCE OF SIGNIFICANT
MORBIDITY AND MORTALITY FOR ELDERLY
PATIENTS.

PROGNOSIS
PATIENTS WITH CARDIAC PROBLEMS HAVE A
MUCH WORSE PROGNOSIS THAN THOSE WITH A
NONCARDIAC OR AN UNEXPLAINED CAUSE.
15% OF PATIENTS HAVE A RECURRENCE OF
SYNCOPE IN AN 18-MO FOLLOW-UP.
VASOVAGAL SYNCOPE AND UNEXPLAINED
SYNCOPE HAVE RECURRENCE RATES: 17% AND
15%
9% OF THE CARDIAC SYNCOPE PATIENTS HAVE A
RECURRENT EPISODE
THERAPIES AIMED AT THE CARDIAC CAUSE MAY
INFLUENCE RECURRENCE RATES.

EVIDENCE-BASED POINTS
FOR SYNCOPE

DIFFERENTIATION OF SYNCOPE FROM DIZZINESS IS ESSENTIAL

FOR BOTH PROGNOSIS AND EVALUATION STRATEGY.

BECAUSE THE PREVALENCE OF CARDIAC DISEASE INCREASES

WITH AGE, CARDIAC CAUSES SHOULD BE CONSIDERED FIRST,
AND ALL PATIENTS SHOULD HAVE A DETAILED CARDIAC
HISTORY AND EXAMINATION AND AN ECG.

MORBIDITY RESULTING FROM FALLS AND ACCIDENTS JUSTIFIES

THE NEED FOR EVALUATION AND TREATMENT OF NONCARDIAC
SYNCOPE.

SYNCOPE FROM ALL CAUSES TENDS TO RECUR.