Syncope and Hypotension in the Elderly Patient

1. 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.

5. 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.

6. 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

7. 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; 39:619

8. 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

9. 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

10. Etiology of Syncope - 4 Unknown No. of Patients No identifiable precipitants 17 Unexplained hypotension 8

11. Elderly patients are at risk of hypotension during common daily activities.

12. Age-related Changes in BP Regulation • Decreased cerebral blood flow • Baroreflex impairment • Reduced renal salt and water conservation • Impaired early diastolic ventricular filling

13. 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)

16. The Higher You Are, The Farther You Fall

17. Honolulu Heart Study Prevalence of OH* Age * 3 min stdg Masaki, Circulation 1998;98:2290

18. Prevalence of OH by Age

19. Prevalence of OH byLevel of Supine SBP

20. Prevalence of OH by Age if Supine SBP > 160 mmHg

21. Effect of Hypotension on the Brain

22. Role of Medications in Hypotension and Syncope?

23. The effect of HCTZ and mild volume contraction on BP response to tilt in healthy young and elderly subjects. Shannon RP, et al, Hypertension 8:438, 1986

24. Orthostatic Hypotension is Reduced By Chronic Antihypertensive Therapy Masuo et al. AJH 1996; 9: 263-8

27. 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.

28. Effect of 6 Months of BP Control on Cerebral Blood Flow Lipsitz, et. al., Hypertension, 2005

30. What’s Different About Syncope in Elderly People? • Multiple Pathologic Conditions • Situational Hypotension • Postprandial • Drug-induced • Orthostatic • Cardiovascular causes > vasovagal • Vasovagal prodrome is less common. • Reflex Syncope - e.g. Carotid Sinus Synd.

31. 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

32. 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

33. 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 < 30; and 8) Primary CNS event.

34. 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.

35. Systemic Hypertension Dehydration Deconditioning Adrenocortical insufficiency Drugs Antipsychotics MAOs & tricyclics antihypertensives (acute doses) vasodilators (NTG) L-Dopa BBs, CCB’s, etc. Causes of OH

36. CNS Disorders Multiple Systems Atrophy Parkinson’s Disease Multiple Strokes Myelopathy Brain stem lesions Autonomic Neuropathy Diabetes Mellitus Amyloidosis Tabes Dorsalis Paraneoplastic Alcohol Nutritional Causes of OH

37. 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.

38. 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

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

40. PPH - Clinical Associations • Patients with HTN, autonomic insufficiency, Parkinson’s 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, TIA’s, lacunar infarcts, leukoaraiosis

41. Evaluation of PPH • BP pre & post meal: 400 kcal, 70-80% CHO. • Hx: Meds, EtOH, autonomic Sx, HTN, DM, CVD, Parkinson’s, autonomic neuropathy. • post-meal EKG to r/o angina. • consider dumping syndrome.

42. 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.

43. Walk

44. Nach dem essen sollst du ruhenoder tausand schritte tuen. -German folk wisdom

45. 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

46. 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.

47. 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.