Abstract
Syncope in the elderly patient is a common presentation and the most common causes
are usually non-cardiac. Older adults however are more challenging dilemmas as their
presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative
disorders. Frailty and cognitive impairment add to the ambiguity of the presentation,
and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope
is a common presentation throughout life even as we age. It has a favorable prognosis
and conservative management usually suffices. Vasovagal syncope in this population
may be misdiagnosed as accidental falls and is frequently associated with injury,
as is carotid sinus syndrome. The initial approach to these patients entails a detailed
history and physical examination including a comprehensive medication history, orthostatic
vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely
helps, unless directed by specific clinical findings. Head-up tilt testing and carotid
sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable
loop recorders provide important information in many elderly patients with unexplained
falls and syncope. The starting point in management of this population with non-cardiac
syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications.
Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited
efficacy and safety concerns. In selected patients, pacemaker therapy might offer
symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach
focused on primary care with targeted specialist referral seems a safe and effective
strategy.
Keywords
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Article info
Publication history
Published online: November 18, 2021
Accepted:
November 13,
2021
Received in revised form:
November 12,
2021
Received:
July 19,
2021
Identification
Copyright
© 2021 Elsevier B.V. All rights reserved.
