Syncope toolkit

Falls and syncope

Syncope and falls increase with age. Contributing factors include changes in body physiology, dehydration and increased mediation use
25% of older people will fall each year, and a fifth of these falls will cause serious injury such as a fractured hip or traumatic brain injury
There is strong consensus that the management of unexplained falls should be the same as that for unexplained syncope
Non-accidental falls (NAF) may represent under reporting of syncope, or present as syncope in older age groups.

A-LoC associated with syncope is a key factor in unexplained falls, especially in older adults. In one study, forty-two per cent of patients over 60 years of age experienced A-LoC post-tilt table induced syncope - they had no recollection of having fainted
To compound this problem, witness accounts are only be available in just over half of older people experiencing syncope
Impaired cognitive function and blood pressure changes do not seem to be risk factors for A-LoC.

It is reported that 30% of patients with carotid sinus syndrome have A-LoC
In patients with unexplained falls 95% had A-LoC during CSS and 27% who presented with syncope had A-LoC
This again illustrates the difficulty in assessing patients who may lack warning symptoms and witness accounts for the event.

Although the first peak of incidence of VVS occurs in teenagers, up to 40% of unexplained recurrent syncope in older individuals is due to VVS, constituting the second peak.(134) The lower reported prevalence of VVS in the older population may be attributable to a lack of prodromal symptoms, unavailable witness accounts, or the presence of cognitive deficits
One trial suggests a prevalence of A-LoC with vasovagal syncope of 28%, with increasing age associated with a higher prevalence of A-LOC but a significant proportion (20%) of younger patients are also affected by A-LOC
Patients with A-LOC and VVS are more likely to have had a fracture associated with a syncopal episode or unexplained fall in the past
NICE guidance Falls Assessment and prevention of falls in older people.

Be aware that amnesia associated loss of consciousness (A-LoC) can make it difficult to diagnose syncope especially in older patients presenting with falls. It is associated with both Vasovagal syncope (VVS) and Carotid Sinus Syndrome (CSS)
Remember cardiovascular events are commonly associated with unexplained falls and recurrent syncope
Falls and syncope place a huge burden on emergency services and are linked to increased mortality, risk of severe injury and reduced quality of life
Distinguishing cardiac syncope from non-cardiac syncope is key due to the increased mortality associated with cardiac syncope; the absence of heart disease can exclude a cardiac cause of syncope in 97% of patients
Measures easily implemented in primary care including lifestyle modifications and reducing or withdrawing culprit measures can effectively prevent vasovagal syncope and syncope due to orthostatic hypotension, and pacing can reduce syncope rates in specific cardiac causes of syncope.