Kenneth M. Madden, MSc, MD, FRCP, VITALITY (Vancouver Initiative to Add Life To Years) Group, Department of Medicine, University of British Columbia, Vancouver, BC.

Orthostatic hypotension (OH), while not itself a disease, is an important physical finding in the setting of unexplained syncope or falls. All antihypertensive medications directly interfere with the normal cardiovascular responses (increased venous return, tachycardia, and vasoconstriction) to orthostatic stress. Regular screening for this condition in older adults with hypertension, as well as careful titration of antihypertensive medications, can greatly improve both mortality and quality of life in this vulnerable population.
Keywords: orthostatic hypotension, postural vitals, antihypertensives, syncope, geriatric medicine.

Maxime Lamarre-Cliche, MD, FRCPC, MSc, Institut de Recherches Cliniques de Montréal, Université de Montréal, Montréal, QC.

Syncope is a frequent cause for emergency consultation and hospital admission; it is also an indicator of reduced survival rate among older adults. The differential diagnosis may be large, but bradyarrhythmias, neurocardiogenic syncope, carotid hypersensitivity syndrome, and orthostatic hypotension are the more frequent causes. Good history-taking and physical examination usually orient the diagnosis and testing strategy. In working with older patients, great care must be taken in assessing comorbidities and concomitant medications as they can exacerbate syncopal symptoms. A multidisciplinary and dedicated approach to syncope increases the diagnostic yield and rapid management of patients.
Key words: syncope, orthostatic hypotension, arrhythmia, neurally mediated syncope.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Kenneth M. Madden, MSc, MD, FRCP(C), Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

Syncope is a common presenting complaint in the older adult population. Unfortunately, cognitive issues and the fact that most falls are not witnessed in older adults can make the separation of falling and syncope quite difficult. In fact, about one third of older adults will have amnesia for faints, even if they are cognitively normal. A systemic approach can help separate cardiac from neurocardiovascular causes and avoid future mortality and morbidity.
Key words: syncope, aging, neurocardiovascular instability, Holter monitoring, tilt table testing.

Gabriel Gregoratos, MD, FACC, Clinical Professor, Emeritus, Division of Cardiology, University of California, San Francisco, CA, USA.

Syncope accounts for six percent of all hospital patient admissions and is a common and frequently debilitating symptom in older patients. The common causes of syncope in older populations are orthostasis, cardiac arrhythmias, neurocardiogenic syncope, and carotid sinus hypersensitivity. The cause of syncope can usually be deduced or suspected by simple initial clinical evaluation. Arrhythmic syncope will usually require ambulatory ECG monitoring or possibly an implantable loop recorder for precise diagnosis. Neurocardiogenic syncope can be frequently confirmed with a tilt-table test and carotid sinus hypersensitivity by careful carotid sinus stimulation during ECG rhythm monitoring. A permanent pacemaker is indicated for all types of symptomatic bradycardia whether complete AV block, severe sinus bradycardia, or the bradycardia-tachycardia syndrome in patients with sinus node dysfunction. Pacemaker therapy is also indicated to prevent certain pause-dependent tachyarrhythmias, although its role in atrial fibrillation remains controversial unless there is clear evidence of bradycardia-tachycardia sequence. Pacing therapy can also effectively treat syncope due to carotid sinus hypersensitivity when the cardioinhibitory component (heart rate slowing) predominates. The role of pacing therapy for neurocardiogenic (vasovagal) syncope remains controversial.
Key words: syncope, pacemakers, neurocardiogenic, carotid sinus, bradycardia-tachycardia.

Derick M Todd MB, ChB, Clinical Fellow, Arrhythmia Service,
University of Western Ontario, London, ON.
Andrew D Krahn MD, Associate Professor, Cardiology, Department of Medicine,
University of Western Ontario, London, ON.

Introduction
A prompt and accurate diagnosis of syncope in the elderly is important in reducing morbidity¹ and mortality, and for maintaining independence.^2,3 The risk of a serious cardiac arrhythmia as the underlying cause for syncope is increased in the elderly, especially in those with an abnormal resting electrocardiogram and/or impairment of left ventricular function.⁴ The key to the diagnosis most often lies in the history from the patient and an eyewitness account. Detecting underlying heart disease by history, clinical examination and a resting 12-lead ECG are crucial in directing further investigation and treatment.⁵ Patients considered likely to have a cardiovascular cause for syncope have a significantly increased mortality rate compared to patients with a non-cardiovascular cause or who remain undiagnosed.⁶ The following case report is intended to illustrate some of these issues.

Rodrigo B. Cavalcanti, MD, FRCP(C)
Clinical Assistant, Internal Medicine, University Health Network.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Staff Physician, Internal Medicine and Geriatrics,
University Health Network, Lecturer, Dept. of Medicine,
University of Toronto, Toronto, ON.

Introduction
Syncope is defined as a transient loss of consciousness accompanied by a loss of postural tone, followed by complete, spontaneous recovery.¹ Population-based studies, such as the Framingham study, indicate that the overall incidence of syncope is 3% per year for men and 3.5% per year for women.² Moreover, syncopal events become more frequent with age, with the incidence rising to 6% per year in persons over 75 years of age.²

It is important to note that syncope is fundamentally a symptom, rather than a disease process, with multiple conditions giving rise to this symptom. The common step in most etiologies is a transitory compromise in cerebral blood flow. Impairment in blood flow to the reticular activating system in the brainstem results in loss of consciousness, while lack of perfusion to the corticospinal pathways impairs motor tone.

Currently, it is estimated that between 2-6% of all hospital admissions are for evaluation of syncope or treatment of associated falls, 80% of which are in persons aged 65 years or older.