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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #42, #54

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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the presentation of syncope and that syncope can mimic falls.

  • Describe the common subtypes and differential diagnosis of syncope.

  • Discuss risk stratification and how risk stratification drives management.

  • Detail pathophysiology of common syncope subtypes in older patients and their management.

  • Discuss the challenges for recognition and management of syncope in the oldest old such as frailty, unwitnessed events, medications, and cognitive impairment.

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Key Clinical Points

  1. Syncope is a common symptom throughout life; however, presentation is more frequent as people age and in the context of comorbidity and multiple medications.

  2. Cardiac causes of syncope become more common with advanced aging.

  3. Etiology in the older patient is often multifactorial.

  4. Presentation in the older patient may result in patients presenting with falls rather than transient loss of consciousness (T-LOC).

  5. Age-related physiologic changes including altered baroreflex sensitivity may result in coexistent supine hypertension coupled with hypotensive syndromes.

  6. The prevalence of hypotensive and bradyarrhythmic syndromes increases due to age-related physiologic changes and/or cardiovascular medications.

  7. Modification of cardiovascular and psychotropic medications is often needed to address syncope in older patients.

  8. Additional challenges in the older patient include frailty, unwitnessed events, polypharmacy, cognitive impairment, and coexistence of multiple causes of syncope.

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DEFINITION

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Syncope is a transient loss of consciousness (T-LOC) due to transient global cerebral hypoperfusion, and is characterized by rapid onset, short duration, and spontaneous complete recovery. T-LOC is a term that encompasses all disorders characterized by self-limited loss of consciousness, irrespective of mechanism. By including the mechanism of unconsciousness, that is transient global cerebral hypoperfusion, the current syncope definition excludes other causes of T-LOC such as epileptic seizures and concussion as well as certain common syncope mimics such as psychogenic pseudosyncope.

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EPIDEMIOLOGY

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Syncope is a common symptom, experienced by up to 30% of healthy adults at least once in their lifetime. Syncope accounts for 3% of emergency department visits and 1% of medical admissions to a general hospital. Syncope is the seventh most common reason for emergency admission of patients over 65 years. The cumulative incidence of syncope in long-term care facilites is close to 23% over a 10-year period with an annual incidence of 6% and recurrence rate of 30%, over 2 years. The age of first faint, a commonly used term for syncope, is less than 25 years in 60% of persons, but 10% to 15% of individuals have their first faint after age 65.

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Syncope due to a cardiac cause is associated with higher mortality rates irrespective of age. In patients with a noncardiac or unknown cause of syncope, older age, a history of congestive cardiac failure, and male sex are important prognostic factors of mortality. It remains undetermined whether syncope is directly associated with mortality or is merely a marker of more ...

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