Syncope in older adults

Syncope can have devastating consequences, resulting in fall-related injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, form a significant and growing socioeconomic burden.

Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in both the ESC Guidelines on Syncope and the World Falls Guidelines published in 2022, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope, making an adequate work-up challenging. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted.

When syncope is mistaken for other causes of a transient loss of consciousness (TLOC), such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimize diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay.

Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment is of great importance in our field.

Age and Ageing have compiled this collection of 15 key syncope themed papers. A commentary to accompany this collection was written by the curators of this themed collection, also published in Age and Ageing: Syncope in older adults: challenges, approach and treatment.

Sofie Jansen

Nathalie van der Velde

Amsterdam UMC, The Netherlands.

The collection:

• Two-year morbidity and mortality in elderly patients with syncope
• Experience of a rapid access blackout service for older people
• Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP)
• Distinguishing syncopal from non-syncopal causes of fall in older people
• New horizons in the ageing autonomic nervous system: orthostatic hypotension and supine hypertension
• Feasibility, reliability and safety of self-assessed orthostatic blood pressure at home
• Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis
• Clinical clustering of eight orthostatic haemodynamic patterns in The Irish Longitudinal Study on Ageing (TILDA)
• New Horizons in orthostatic hypotension
• Randomised controlled trials of antihypertensive therapy: does exclusion of orthostatic hypotension alter treatment effect? A systematic review and meta-analysis
• Vasovagal syncope in the older person: differences in presentation between older and younger patients
• Safety and tolerability of Tilt Testing and Carotid Sinus Massage in the octogenarians
• The usefulness of carotid sinus massage in different patient groups
• AF is associated with self-reported syncope and falls in a general population cohort
• Self-reported cardiovascular conditions are associated with falls and syncope in community-dwelling older adults