Syncope and Hypotension in the Elderly Patient

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Syncope and Hypotensionin the Elderly Patient

• Lewis A. Lipsitz, MD
• Hebrew SeniorLife,
• Beth Israel Deaconess Medical Center,
• Harvard Medical School

Disclosures None
2
Syncope Definition

• Transient loss of consciousness, characterized
  by unresponsiveness and loss of postural tone,
  with spontaneous recovery.

3
Epidemiology of Syncope

• Prevalence up to 47 in healthy young
• 23 10-year pevalence in the NH pop.
• 6-33 1-year mortality in pts. over 60.
• 2 Billion annual costs.
• Up to 40 of cases remain unexplained, despite
  extensive inpatient evaluations.

4
Syncope Case 1

• An 88 year old nursing home resident with
  hypertension, CAD, and mild dementia was found
  unresponsive and slumped in her chair, 1 hour
  after breakfast. She had taken isosorbide
  dinitrate, metoprolol, lisinopril, and HCTZ
  before breakfast. Her BP was 105/72, pulse was
  64.

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Syncope Case 2

• An active 75 y.o. man with no active medical
  problems suddenly became dizzy and fainted while
  cleaning his apartment. A friend found him and
  rushed him to the hospital where he was admitted
  and ruled out for an MI. A head CT and exercise
  stress test were normal. BP and P were 158/92,
  72 supine and 90/62, 72 standing.

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Syncope Etiology

• Only if one knows the causes of syncope will he
  be able to recognize its onset and combat the
  cause.
• Miamonides
• 1135-1204 CE

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Etiology of Syncope in the NH

• Diseases No. of Patients
• Myocardial Infarction 6
• Aortic Stenosis 5
• Dehydration 4
• Seizure Disorder 3
• Cerebrovascular Event 3
• Cardiac Ischemia 3
• Tachy-Brady Syndrome 3

Lipsitz, LA, J Chronic Ds, 1986 39619
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Etiology of Syncope - 2

• Diseases No. of Patients
• Acute respiratory failure 2
• Cervical Spondylosis 1
• Sinus arrest 1
• Paroxysmal atrial tachycardia 1
• Carotid sinus syndrome 1
• Heart block 1

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Etiology of Syncope - 3

• Situational Stresses No. of Patients
• Drug-induced hypotension 11
• Postprandial hypotension 8
• Defecation/colostomy irrigation 7
• Orthostatic hypotension 6
• Fecal impaction 3
• Vomiting 1
• Micturition 1
• Bending over 1

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Etiology of Syncope - 4

• Unknown No. of Patients
• No identifiable precipitants 17
• Unexplained hypotension 8

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Elderly patients are at risk of hypotension
during common daily activities.
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Age-related Changes in BP Regulation

• Decreased cerebral blood flow
• Baroreflex impairment
• Reduced renal salt and water conservation
• Impaired early diastolic ventricular filling

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Aging, Hypertension, and BP Regulation
Aging
BP Elevation
Impaired BP Regulation
Hypotension
Cerebral Hypoperfusion
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Blood Pressure Equation

• BP HR x SV x SVR

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Cardiovagal baroreflex gain declines with age.
Gribbin et al. Circ. Research, 29426, 1971
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Age-related Changes in Plasma Norepinephrine
17
Aged-related Increase in Sympathetic Response to
Orthostatic Stress
Davy et al, HTN 1998
18
Age-related Decrease in Vascular Response to
Sympathetic Activity
Davy et al, HTN 1998
19
Reduced Salt and Water Conservation
Adapted from Epstein, et al, Fed Proc 1979 170.
20
Age-related Change in Plasma Renin Activity
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Diastolic Dysfunction
A
A
Normal transmitral Doppler ventricular inflow
pattern
Reduced early, increased late diastolic
ventric.filling
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190
SUP
STD
BREAK
STD/AMB
NTG
STD
AMB
MED
LUNCH
STD
170
150
SBP (mm Hg)
old
130
young
110
90
9
7
8
10
11
12
1
Time (hours)
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The Higher You Are, The Farther You Fall
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Honolulu Heart Study Prevalence of OH
Age
3 min stdg
Masaki, Circulation 1998982290
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Prevalence of OH by Age
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Prevalence of OH byLevel of Supine SBP
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Prevalence of OH by Age if Supine SBP gt 160 mmHg
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Effect of Hypotension on the Brain
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Role of Medications in Hypotension and Syncope?
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The effect of HCTZ and mild volume contraction
on BP response to tilt in healthy young
and elderly subjects.
Shannon RP, et al, Hypertension 8438, 1986
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Orthostatic Hypotension is Reduced By Chronic
Antihypertensive Therapy
Masuo et al. AJH 1996 9 263-8
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Does Antihypertensive Therapy Threaten Cerebral
Blood Flow?

• Sit-to-stand Procedure
• Avoids hydrostatic changes in perfusion pressure
  (vs. tilt).
• Simulates a common activity of daily living.
• Causes rapid and reproducable declines in
  arterial pressure.

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Effect of 6 Months of BP Control on Cerebral
Blood Flow
Lipsitz, et. al., Hypertension, 2005
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Whats Different About Syncope in Elderly People?

• Multiple Pathologic Conditions
• Situational Hypotension
• Postprandial
• Drug-induced
• Orthostatic
• Cardiovascular causes gt vasovagal
• Vasovagal prodrome is less common.
• Reflex Syncope - e.g. Carotid Sinus Synd.

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Syncope Evaluation

• Hx of diseases, drugs, and precipitants
• PE for CV ds., neuro signs, GI bleeding
• BP during activities preceding syncope posture
  change, meals medications.
• Carotid sinus massage (if no CVD or cardiac
  conduction disease)
• Focused laboratory studies

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Syncope Evaluation - Labs

• For most patients EKG, Chem screen, CBC.
• If cardiac sx, or abnormal EKG - r/o MI
• If Hx of CVD - ambulatory cardiac monitor
• If situational - ambulatory BP monitoring
• If suspicious murmur - cardiac echo/Doppler
• If focal neuro findings or Seizures - EEG/CT
• If unexplained - Tilt and EPS

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Whom to Admit? Boston Syncope Rule (97 Sens.,
62 Spec. for adverse outcome or critical
intervention (Grossman, JEM 2007))

• 1) Signs and sx of an acute coronary syndrome
• 2) Signs of conduction disease
• 3) Worrisome cardiac history
• 4) Valvular heart disease by history or physical
  
• 5) Family history of sudden death
• 6) Persistent abnormal vital signs in the ED
• 7) Volume depletion such as persistent
  dehydration, GI bleeding, or hematocrit lt 30 and
• 8) Primary CNS event.

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Definition of Orthostatic Hypotension

• 20 mmHg or greater decline in systolic BP and/or
  10 mmHg or greater decline in diastolic BP when
  changing from a supine to upright position
  (sitting or standing).
• 1 and/or 3 minute value.
• HR is not a reliable indicator in geriatric
  patients because of baroreflex impairment.

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Causes of OH

• Systemic
• Hypertension
• Dehydration
• Deconditioning
• Adrenocortical insufficiency

• Drugs
• Antipsychotics
• MAOs tricyclics
• antihypertensives (acute doses)
• vasodilators (NTG)
• L-Dopa
• BBs, CCBs, etc.

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Causes of OH

• Autonomic Neuropathy
• Diabetes Mellitus
• Amyloidosis
• Tabes Dorsalis
• Paraneoplastic
• Alcohol
• Nutritional

• CNS Disorders
• Multiple Systems Atrophy
• Parkinsons Disease
• Multiple Strokes
• Myelopathy
• Brain stem lesions

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Evaluation of OH

• Sx Postural dizziness, falls, or syncope po
  intake abnl. sweating, incontinence, HA,GI
  dysmotility, impotence, poor night vision.
• Hx HTN, DM, CA, Stroke, Parkinsons, Arrhythmias,
  Meds alcohol.
• PE BP P supine, 1 3 min stdg pupils, skin,
  CV and neuro exams.
• Labs Hct, Lytes, Glu, SPEP, B12, RPR /-
  cortisol, brain imaging, tilt with NE levels, HRV
  during deep breathing Valsalva, sweat tests.

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Nonpharmacologic RX of OH

• Drug withdrawal, substitution or reduction
• Avoid warm environment
• Avoid straining activity
• Squatting, leg crossing
• Increase salt intake
• Waist-high compression stockings
• Sleeping in the head-up position

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Definition of PPH

• 20 mm Hg or greater decline in systolic BP
  within 2 hours of the start of a meal.

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PPH - Clinical Associations

• Patients with HTN, autonomic insufficiency,
  Parkinsons Disease, Diabetes, Renal failure
• 24-36 of nursing home residents.
• 23 of elderly patients admitted to a geriatric
  hospital with syncope or falls.
• 50 of elderly pts. with unexplained syncope
• Angina, TIAs, lacunar infarcts, leukoaraiosis

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Evaluation of PPH

• BP pre post meal 400 kcal, 70-80 CHO.
• Hx Meds, EtOH, autonomic Sx, HTN, DM, CVD,
  Parkinsons, autonomic neuropathy.
• post-meal EKG to r/o angina.
• consider dumping syndrome.

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Nonpharmacologic Rx of PPH

• Stop hypotensive meds or give between meals.
• Avoid preload reduction (diuretics or prolonged
  sitting), maintain adequate intravascular vol.
• Avoid EtOH.
• Multiple small meals of protein and fat.
• Walking exercise after meals (frail elderly).
• ? cold rather than warm meals.

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Walk
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Nach dem essen sollst du ruhenoder tausand
schritte tuen.

• -German folk wisdom

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Pharmacologic Rx of OH and PPH

• Caffeine 250 mg (2 cups brewed) in AM
• Fludrocortisone 0.1 to 1.0 mg QD (watch for CHF,
  supine HTN, and hypokalemia.
• Midodrine 2.5-10 mg po TID (supine HTN)
• Octreotide 50 mg subQ, 30 min. pre-meals

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Challenges and Unmet Needs

• 1. Causes of Unexplained Syncope?
• Neurally-mediated (vasovagal) fewer premonitory
  sx in elderly patients.
• Dysautonomia
• Paroxysmal brady- or tachy-arrhythmias
• Carotid Sinus Hypersensitivity
• 2. Better Diagnostic tools Tilt tests, EPS, BP
  monitoring? Validate Syncope Rule in Elderly
• 3. Methods to improve cerebral perfusion.

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Principles of Treatment

• Treat the primary etiology if one is found.
• Age is NOT a contraindication to treatment, but
  increases the risk of drugs and surgery.
• Identify and minimize the impact of multiple
  contributors, particularly drugs.
• Behavioral interventions to avoid situational
  hypotension.