Transcript Falls, Dizziness and Syncope in older people

Syncope
Frances Dockery
Dept. of Ageing and Health
St Thomas’ Hospital
London
SYNCOPE – a particular kind of fall
William Stokes
Robert Adams
Derived from Greek work synkoptein, meaning “to cut short”
Hippocrates may have first described it
SYNCOPE – a particular kind of fall
• Sudden Loss of consciousness and loss of
postural tone, due to cerebral hypoperfusion
• Brief, with quick recovery
• Retrograde amnesia common in elderly; many
deny LOC (up to 30% of witnessed syncope on
tilting)
Classification of true syncope*
European Society of Cardiology
• Neurally-mediated or ‘reflex’ syncope
– Vaso-vagal syncope
– Situational syncope
– Carotid sinus syndrome
• Orthostatic hypotension
– Autonomic failure
– Drugs
– Volume depletion
• Cardiac
– Arrhythmic
– Structural – AS, HOCM, pulmonary embolus, aortic dissectioin
Causes of syncope
• Framingham Data, Soteriades, NEJM 2002:
• Of 7814 study participants mean age 51 years, followed
for an average of 17 years, 822 reported syncope
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>30-40% unknown
20% vaso-vagal
10% cardiac
10% orthostatic
10% medication
5% each epilepsy & TIA
10% other
SYNCOPE OUTCOMES
Framingham data. Soteriades, NEJM 2002
Syncope Incidence vs. Age
Framingham data. Soteriades, NEJM 2002
Older people and syncope
AGE GROUP
All pts
18-39y
40–59Y
60–79Y
≥80Y
n=477
n=141
n=112
n=115
n=109
80 (17)
4 (3)
15 (13)
30 (26)
31 (28)
Odds ratio (95% CI)
—
—
3.8 (1.4-9.9)
8.3 (3.3-21)
9.8 (3.9-24)
Arrhythmia, n
34
1
7
12
14
Traumatic injury, n
10
0
1
4
5
Pacemaker
placement, n
7
0
0
2
5
14-day post syncope
Patients with any
event, n (%)
Sun et al, JAGS 2007
Older people and syncope
Risk factors for severe outcome 1-year post ED visit
Logistic Multivariate Regression
Adjusted OR
Age >65 yrs
3.4
Neoplasms
3.2
Cerebrovascular
2.5
diseases
Structural heart
2.3
disease
Ventricular
3.9
arrhythmias
95% CI
1.6–7.4
1.6–6.5
p
.001
.001
1.3–4.7
.006
1.3–4.2
.004
1.0–15.3
.049
Costantino, JACC 2007
Mrs. MB
• 84 year old lady
• Recurrent falls x 2 years, some with dizziness,
others without warning
• History: Hypertension, Glaucoma
• Medications: Amlodipine, Timolol eye drops
• 24hr ECG, lying and standing blood pressures N
• WHAT NEXT?
Supine carotid sinus massage
BLOOD PRESSURE ON CSM
SBP
DBP
HR
How would you manage her?
• Pacemaker?
• Stop anti-hypertensive?
• Stop eye drops?
• All of the above?
• Observe?
Carotid sinus syndrome
- 5-8 seconds of firm pressure at point of maximum pulse
- CI –recent stroke, carotid bruits, known carotid stenosis
- Stroke risk: 0.25%. 0.01% permanent deficit
>3 second pause
>50mmHg SBP drop
‘Hypersensitivity’ if asymptomatic
‘Syndrome’ only if symptomatic
CSH - History
• Parry in 1799 described slowing of the heart in response
to carotid sinus pressure
• Johann Czermak 1865 - self-stimulated  syncope
ORIGIN OF CURRENT DIAGNOSTIC CRITERIA:
• Franke 1963 performed CSM in 3,900 patients
• Sigler 1963 CSM in 1,886 patients
– 10% had CSH response of >3 sec pause + / - 50mm Hg BP drop.
Most had some kind of symptoms
– Age, male sex, cardiac disease main predictors
CSH in older people
• Random community sample >65yrs 272 pts
• Kerr, Arch Int Med 2006
• 39% had CSH
– 24% had cardio-inhibitory (pause >3sec)
– 16% were symptomatic
• 80 of the group had no previous falls / dizziness
– 10 had symptomatic cardio-inhibitory CSH
– Predictors: Male sex & age
Cause
• Unclear…
Reflex syncope – Pathophysiology
CSS Pathophysiology
• Cardio-inhibitory CSS - overlap with sick sinus syndrome
• Impaired cerebral auto-regulation 2º to neuro-degeneration
(?cause & effect)
(Kennelly, J Ageing Res Reviews 2009)
• Increased arterial stiffness, causing greater arterial wall
pressure, reduced vessel capacitance
(Madden, Aging Clin Exp Res. 2010)
• VDR patients have greater blood pressure variability,
reduced baro-reflex sensitivity
(Finucane,Europace 2010)
Pacing Intervention CSH (with
cardio-inhibitory component)
• SAFEPACE 1 - (Kenny, JACC 2001)
– Single site RCT
– PPM vs. controls n= 175 . MMSE>24
– 70% reduction if falls risk
• SAFEPACE 2 - ( Ryan, Heart 2010)
– Multicentre RCT PPM vs. loop recorder n=145 MMSE>19
– Similar reduction in falls and syncope in both groups
• PERF - (Parry, Heart 2009)
– Single site RCT cross-over n=34 MMSE >20
– PPM switched on/off x 6 months each – BLINDED
– Similar reduction in falls in both groups
Explanations..?
• CSM – operator-dependent technique
• Large placebo effect following device insertion
– Falls risk post loop: 0.23 (95% CI 0.15 - 0.37)
– Concurs with results in cardio-inhibitory vaso-vagal syncope
(VPS2, SYNPACE)
• Overlap between falls and syncope in older people
– Single intervention insufficient, multifactorial intervention
warranted in older patients with syncope
Back to case 1 Mrs. MB: Management
• Stopped Amlodipine and Timolol drops
• Repeat tilt 8/52
Follow-up Carotid sinus massage, supine
8/52 tilt test, carotid sinus massage
SBP
DBP
HR
Mr EJ
• 81 year old male
• Admitted with collapse while walking
• Several falls, dizzy spells for years
• ‘”Moderate” drinker. No medications
• Cerebellar signs, Orthostatic hypotension
• ECG: 1° heart block, 24-hr ECG, Echo normal
• Bedside CSM – 2.5 second pause
• Outpatient tilt test
Carotid sinus massage upright
10.5 sec pause
What will you do?
• Pacemaker?
• Will it stop him from falling?
Pacemaker inserted July 2006
PNEUMOTHORAX !!
2 week inpatient stay
PROGRESS
• Discharged September 06
• PPM lead repositioned 13th Dec 06
• Removed 24th Dec 06
• Reinserted 1st Feb 07
• Still dizzy, still falling, but frequency reduced
• Gets to the pub!
• Severe orthostatic hypotension persisted:
– 170mmHg  80mmHg SP on immediate standing
• HIP FRACTURE JANUARY 2008…
Recovers, discharged home
• WHAT ELSE CAN WE DO
SUGGESTIONS?
• Ban him from the pub?
• TRIED ! His only social activity (and his choice).
• Exercise program/physiotherapy?
• YES – Local falls prevention 8-week exercise class
• Osteoporosis treatment?
• YES – DXA scan. AdCalD3 and Alendronic acid
• Treat his orthostatic hypotension (and likely persistent
vasodepressor carotid sinus syndrome)
– ? HOW ?HOW…
Orthostatic hypotension
• Failure to maintain blood pressure on standing
• >20mmHg SBP drop within 3 mins of standing (or ‘delayed
orthostatic hypotension 3-30 mins later).
• Heart rate response often blunted
• Medications prime cause – anti-hypertensives, anti-cholinergics
• Alcohol
• Aortic stenosis
• Autonomic neuropathy (and all its causes..)
• Variable – with time of day, hydration status
• (make sure not Addisonian)
OH Symptoms
• Light-headedness, dizziness
• General weakness, fatigue, nausea, legs buckling,
headaches
• Post-prandial collapse
• ‘Coat-hanger pain’
• Angina from impaired myocardial perfusion
• Nocturnal polyuria (supine hypertension)
Vaso-depressor CSS … the “boring” bit !!
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Poorly understood
Few trials
Little evidence
No definite effective measures
• Largely ignored…
Vaso-depressor CSS / Vaso-vagal / OH (neurallymediated or reflex syncope)
• Stop hypotensive med’s (treat standing BP)
- Physical manoeuvres – leg crossing, muscle tensing
(Van Lieshout Lancet 1992)
- Increase fluid, salt intake (care in hypertensives)
- TEDS (care with PVD). Abdominal wall binders
- Raise head of bed by 6” (reduce nocturnal polyuria)
- Medications (largely ineffective)
- Tilt ’training’ (vaso-vagal syncope)
- Cognitive behavioural therapy
Sustained benefit of water drinking in OH
Jordan et al, Circulation 2000
Clear soup gave opposite effect to
water in MSA – probably elicits
post-prandial hypotension
(Z’graggen, Eur J Neurol 2010)
Drugs to treat CSH (VDR), OH,
Vaso-vagal syncope
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Fludorcortisone
Weak evidence (and NONE in CSS (VDR)
Pyridostigmine
•Single centre
Erythropoeitin
•Small numbers
Ephedrine
•Non-blinded
Desmopressin
Paroxetine
Midodrine – centrally acting α agonist
– Multi-centre double-blind RCT in OH
– n=171 6-week duration
– Improved standing BP and symptom score
(Low, JAMA 1997)
• Side Effects – Urinary retention, supine hypertension
Mr EJ – Ongoing treatment
• Fludocortisone – no help
• Midodrine started mid-2006 after PPM
– stopped as supine BP’s >200 and only minor benefit
• Pyridostigmine started – ineffective
• Midodrine added again, at lower dose
• Large BP drop persisted, though improved
• Decreased his alcohol intake
• No admission since hip fracture Jan 2008…
Assessment of suspected syncope
• History - including witness if available
• ECG
• Lying and standing blood pressure - Supine for at
least 10 minutes, standing for 3 minutes
• 24-hour ECG - pick-up very low if ECG normal
• Echocardiogram - If aortic stenosis suspected
clinically - or low ejection fraction (ventricular
arrhythmia more likely)
• Tilt-table testing
Tilt table testing
1.
Evaluate response to carotid
sinus massage in supine &
upright position
2.
Evaluate orthostatic blood
pressure response
3.
Prolonged stand – for
diagnosis of vaso-vagal
syncope
4.
GTN, Atropine, Adenosine,
Isoprenaline can be used
Mr RD
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74year old chaplain at university – “busy, under stress”
Collapse while out walking – 1st episode
No recollection. No witness
Extensive facial bruising, fractured orbit
CABG 10 years ago. No problems since. Very active
• ECG ok, Echo and 24hr tape NAD – discharged
• Tilt test – vasodepressor response and mild OH
• 1 further episode 2 months later while seated at table
• NEXT STEP?
Catching the Arrhythmia…
Implantable
Loop Recorder
• ~ £1500
• Last up to 3 y
• Patient and / or
auto-activated
• Some problems
with autoactivation but
technology
improving
ILR in unexplained syncope
• EaSyAS study (Farwell, 2004)•
• District hospital UK
• 201 patients with
•
unexplained syncope
• Mean age 74
• Randomised after basic
clinical workup to ILR or
conventional investigation.
• F/U over > 6 months
• Outcome: time to ECG •
diagnosis
Diagnosis in 33% ILR vs. 4%
conventional (p<0.001)
ILR group
– Quicker ECG diagnosis
– Fewer investigations
– Fewer hospital days
– Reduced costs
Dramatic decline in
syncope incidence during
follow-up…
ILR in unexplained syncope
A dizzy patient
• Female, 84 years
• Recurrent falls, referred for tilt table test for falls often
preceded by dizziness, denied blackouts
• Med’s: analgesia, Vitamin D
• Tilt test: unable: dizzy++ on lying supine
• Hx of 6-pillow orthopnoea x years for dizziness!
Ageing - Dizziness
• Most common symptom reported to GPs’ in>65 year olds
• Vestibular cause least likely; ENT referral not appropriate
1st line
• Medications – main culprit
• Brief: OH, CSH, arrhythmia/AS, BPPV
• Hours: Meniere’s diesease, migraine
• Weeks: Central / Vestibular
• Vestibular nerve lesion (neuronitis, ischaemic, etc.)
• Brainstem / Cerebellar lesion
BPPV - Benign paroxysmal positional vertigo
Infrequent, but a worthwhile diagnosis in a dizzy patient
Hallpike’s test
Epley’s manoeuvre
>90% cure rate
Look for nystagmus + symptoms
Lempert T, BMJ 1995;311:489-491
BPPV
• Brand-Daroff (home based)
• Cawthorne-Cooksey (in vestibular failure)
– Vestibular rehabilitation
Thank you for
listening
Any Questions?