“Old age starts with the first fall and death comes with the second.”1
Syncopal events and falls are a major healthcare and cost burden for the National Health Service (NHS). Each year between 35% of community living adults over 65 years and 45% of adults over 80 years have such an event.2 This common medical problem accounts for up to 6% of emergency medical admissions. We have previously shown the potential impact that a dedicated syncope and falls facility for older adults can have enabling an attributable diagnosis and on emergency bed usage.3,4
In this issue Ali et al. (see pages 22–8) further emphasise the need and benefits for the development of rapid access blackout clinics. They describe a comprehensive investigation pathway and highlight the importance of making a correct diagnosis and the implications of an incorrect one. It is still the case that a diagnosis is elusive in up to 40% of cases.4,5
They point out that even in those who do receive a diagnosis it may be incorrect. This is particularly so within the older age group. In relation to the diagnosis of ‘epilepsy’ the authors highlight that up to 100,000 people in the UK live with the moniker but without the condition. This has significant implications for public health including utilisation of inappropriate and expensive therapy.
Prognostic implications
There are profound prognostic implications for those suffering from syncope – Soteriades et al., in their study, evaluated the incidence and prognosis of syncope in participants in the Framingham Heart Study.5 They found the most frequently identified causes were vasovagal syncope, cardiac syncope and orthostatic hypotension: 36% still had no demonstrable cause. There was no increased risk of cardiovascular morbidity or mortality associated with vasovagal syncope, but persons in this study who fell into the diagnostic categories of cardiac syncope or syncope of unknown cause, were at increased risk of death from any cause.
While respecting that blackouts can occur in all age categories, and accepting the clear bimodal age distribution, this area is particularly challenging in the elderly. Epidemiological data demonstrate an increasing prevalence of blackouts and falls with age. This, coupled with co-morbidities, dependency and dementia, as well as the observation that the incidence of injuries sustained in the fall increases dramatically with age,6 make this a priority area in healthcare.
A public health priority
This public health priority has been captured by the Department of Health in the UK and incorporated into Standard 6 of the National Service Framework for Older People.7 The development of rapid access blackout clinics is concordant with this standard.
The authors highlight and concur with the diagnostic approach suggested by the European Society of Cardiology and it is heartening to see that the fundamentals of clinical medicine – a good history and examination allied to judicious use of simple tests – remain the cornerstone of investigation.
A cautionary note needs to be struck when one considers patients with dementia. These are a particularly frail group with an annual fall rate of 40–60%.8 In addition, retrograde amnesia for loss of consciousness results in confusion between syncope and falls.9 This adds to the complexity of the evaluation process and recourse to a strong, interested and focused multi-disciplinary team is invaluable in relation to optimising care. This multi-disciplinary team should be led by a cardiologist, neurologist or geriatrician, but most importantly by a motivated physician with a particular interest and specific training in the area.
The rapid access blackout clinic is a prudent, sensible and reasonable response to the increasing burden posed by loss of consciousness. It should certainly add value, diagnostic efficiency, improved patient outcome and cost-effectiveness to the patient journey.
Conflict of interest
None declared.
Editors’ note
The article on rapid access blackout clinics by Ali et al. can be found on pages 22–8 of this issue.
References
- Garcia Marquez G. Love in the time of cholera. Penguin Books, 1994.
- O’Shea D. Setting up a falls and syncope service for the elderly. Clin Geriatr Med 2002;18:269–78.
- Kenny RA, O’Shea D, Walker HF. Impact of a dedicated syncope and falls facility for older adults on emergency beds. Age Ageing 2002;31:272–5.
- Allcock LM, O’Shea D. Diagnostic yield and development of a neurocardiovascular investigation unit for older adults in a district hospital. J Gerontol A Biol Sci Med Sci 2000;55:M458–M462.
- Soteriades ES, Evans JC, Larson MG et al. Incidence and prognosis of syncope. N Engl J Med 2002;12:878–85.
- Kannus P, Parkkari J, Koskinnen S et al. Fall induced injuries and deaths amongst older adults. JAMA 1999;281:1895–9.
- Department of Health. National service framework for older people. London: DoH, 2001.
- Morris JC, Rubin EH, Morris EJ, Mandel SA. Senile dementia of the Alzheimer’s type, an important risk factor for serious falls. J Gerontol 1987;42: 412–17.
- McIntosh SJ, Lawson J, Kenny RA. Clinical characteristics of vasodepressor, cardioinhibitory and mixed carotid sinus syndrome in the elderly. Am J Med 1993;95:203–08.
