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“The incidence of syncope in older adults may overlap with falls, so it may be difficult to distinguish one from the other. The management of syncope in older adults is particularly challenging. The incidence is high; the differential diagnosis is broad; the diagnosis is imprecise …”

From the ACC/AHA/HRS Guidelines for the Evaluation and Management of Patients with Syncope (2017)

“Given that up to 70% of falls in older persons are not witnessed, these patients may present with a report of a fall rather than syncope.”

From the AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2011)


Falls and syncope are commonly encountered syndromes in older adults, and both are associated with significant morbidity and mortality. It is often difficult to know when to consider syncope as the primary or a contributing cause to falls in older adults. In part, for this reason, current guidelines recommend evaluating patients with unexplained falls for syncope. This chapter provides some guidance for the clinician faced with the question, “Is this patient’s fall caused by syncope?”

Most studies estimate that one-third of community-dwelling older adults fall each year. Falls are the leading cause of injury among patients age 65 years and older. Up to nearly 40% of falls among older adults result in injury or restricted activity. Falls are associated with functional decline, increased risk for nursing home placement, decreased quality of life, higher health care costs, and mortality.

Syncope is also common among older adults. Its prevalence in the general population has a trimodal distribution peaking in people at age 20 years, at age 60 years, and again in those age 80 and older. Almost half of emergency department visits for syncope are made by persons 65 years of age or older. Because of underlying multiple chronic conditions and increased prevalence of cardiovascular disease in older people, the morbidity and mortality associated with syncope are higher in older adults compared to younger adults.


A. Falls

The literature varies widely on the definition of falls, but typically falls are defined as unintentionally coming to rest on the ground or a lower surface. When evaluating a patient with falls, obtaining a detailed history of the fall from the patient and witnesses, if available, is imperative and a good starting point. This history should include the circumstances surrounding the fall; any preceding symptoms, such as dizziness or lightheadedness; whether the fall was witnessed or not; and whether there was loss of consciousness with the fall. A focused physical exam including a cognitive and functional assessment should also be completed. During the evaluation, it is important to remember that falls constitute a geriatric syndrome. As such, the cause of falling in an older patient is rarely the result of ...

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