One of the greatest achievements of public health in the twentieth century has been the almost doubling of life expectancy in the Western world. Yet this now ageing population brings new challenges, as the prevalence of little-understood geriatric conditions increases, together with the rising prevalence of age-related disorders, such as syncope.
The definition of syncope, as outlined by the European Society of Cardiology (ESC), is a transient loss of consciousness (T-LOC) due to global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery.1 Previous variations in the definition of syncope have led to its prevalence being poorly appreciated.2 By distinguishing syncope/T-LOC from other causes of loss of consciousness (for example, epileptic seizure, concussion), the present definition aims to minimise conceptual and diagnostic confusion.1
Why is syncope in the elderly important? Presentation in this age group is challenging and often recognition is the first step to optimising management and care of these patients. To start with, syncope in the older patient is under-recognised, particularly in acute care settings because the presentation is frequently atypical.
The older patient is less likely to have a warning or prodrome prior to syncope, commonly has amnesia for loss of consciousness and frequently experiences an unwitnessed event,3 thus presenting with a fall rather than T-LOC.4–6 These events are typically described as non-accidental (not a trip or slip) or unexplained falls. Therefore, history alone cannot be relied upon when assessing the older patient. Injurious events such as fractures and head injuries, are also more common, further emphasising the importance of thorough early investigation and diagnosis.3
There is an increased susceptibility to syncope with advancing age that is attributed to age-related physiological impairments in heart rate (HR), blood pressure (BP), cerebral blood flow and neurohumoral stability.7 This, combined with multi-morbidity and polypharmacy in these complex patients adds to their vulnerability.7 Furthermore, cardiac causes are more common as patients age.8 Emerging evidence has proposed consideration of early insertion of patient-activated internal loop recorder (ILR) devices in this age group.9,10
In the older patient, syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs.7 Quality of life studies have consistently shown that functional impairment induced by syncope is similar to that of chronic diseases such as rheumatoid arthritis and epilepsy11–13 underscoring the significant morbidity attached to syncope.
The purpose of this review is to highlight the characteristics and epidemiology of syncope in the older person.