From the Guidelines
Admitting an 87-year-old patient who presents to the Emergency Department with a syncopal episode is recommended, even if all laboratory tests are normal, due to the higher risk of serious underlying causes and potential for complications. Syncope in elderly patients warrants thorough evaluation, as seen in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The initial workup should include an ECG, cardiac monitoring, orthostatic vital signs, and a detailed neurological examination. Consider ordering an echocardiogram, as recommended by the guideline, which states that transthoracic echocardiography can be useful in selected patients presenting with syncope if structural heart disease is suspected 1.
Some key points to consider in the evaluation and management of syncope in elderly patients include:
- The risk of cardiac arrhythmias, structural heart disease, or cerebrovascular events is higher in this age group
- Elderly patients have less physiological reserve and higher risk of complications following syncope, including injuries from falls
- Medication review is essential, as polypharmacy is common in this age group and can contribute to syncope through mechanisms like orthostatic hypotension or QT prolongation
- Even with normal initial labs, the cause of syncope remains undiagnosed in approximately 40% of cases at presentation, and hospitalization allows for observation and more comprehensive evaluation to identify potentially life-threatening conditions. The 2001 clinical policy on syncope also supports admission for patients with certain high-risk features, although this guideline is less recent than the 2017 ACC/AHA/HRS guideline 1.
From the Research
Evaluation of Syncope in the Elderly
The evaluation of syncope in the elderly can be complex due to the presence of comorbidities and cognitive impairment 2. A thorough history and physical examination, including orthostatic assessment, are crucial for making the diagnosis 3.
Diagnostic Approach
The diagnostic approach to syncope in the elderly involves:
- Initial evaluation, including anamnesis, medical examination, orthostatic hypotension test, and electrocardiogram (ECG) 2
- Neuroautonomic assessment to confirm a suspect of neuromediated syncope 2
- Orthostatic blood pressure measurement, head up tilt test, carotid sinus massage, and insertable cardiac monitor as safe and useful investigations 2
- Evaluation of cardiac syncope, which is similar in older and young patients 2
Admission Decision
The decision to admit a patient with syncope to the hospital can be guided by various risk prediction scores 4. If the short-term risk is high, inpatient evaluation is needed, while outpatient evaluation is recommended if the short-term risk is low 3.
Management of Syncope
The management of syncope in the elderly involves:
- Tailoring therapy based on the underlying etiology of syncope 4
- Addressing orthostatic hypotension, drug therapy, and pacemaker implantation as necessary 2
- Considering the potential implications of successful interventions for cardiovascular disorders that cause syncope, including reductions in falls and possibly prevention or modification of cognitive impairment and dementia 5
Key Considerations
Key considerations in the evaluation and management of syncope in the elderly include:
- The presence of comorbidities and cognitive impairment, which can confound the assessment of syncope 5
- The potential for syncope to present as falls, particularly in patients with retrograde amnesia 2
- The importance of a standardized approach to obtain a definite diagnosis and reduce diagnostic tools and hospitalizations 2