Evaluation and management of syncope and related disorders in older adults

Syncope is a common clinical condition in the older population. The diagnostic and therapeutic management may be complex, particularly in older adults with syncope and comorbidities or cognitive impairment. A standardized approach may obtain a definite diagnosis in more than 90% of the older patients and reduce health care costs for unnecessary diagnostic tests and hospitalizations. The initial evaluation, including clinical history, physical examination, active standing test, and 12-lead electrocardiogram, may be more difficult in the elderly, especially for the limited value of clinical history, particularly for the certain diagnosis of neuromediated syncope. Orthostatic blood pressure measurement, tilt testing, carotid sinus massage, and insertable cardiac monitor are safe and useful investigations, particularly in older patients. There are no consistent differences in the treatment of syncope between the older and younger populations, but a specific approach is necessary for orthostatic hypotension, drug therapy, and pacemaker implantation. The prevalence of syncope increases with advancing age. The diagnosis of syncope in the older population may be complex due to atypical presentations, amnesia for the loss of consciousness, absence of witnesses, and the overlap with other clinical presentations such as falls. Age per se should not limit the assessment and treatment of syncope. A comprehensive assessment of comorbidities and drug regimen is mandatory. A standardized guidelines-based approach based on blood pressure measurement in the supine and upright position, carotid sinus massage, and tilt testing is well tolerated in older patients. Prolonged electrocardiogram monitoring has increased the diagnostic yield for cardiac syncope. The treatment of syncope ranges from nonpharmacological measures to permanent cardiac pacing.