Experience of a rapid access blackout service for older people

SIR—Syncope is experienced by almost half the population during a lifetime [1, 2] and accounts for significant morbidity [3–5]. The overall incidence in community-dwelling older people is reported as 6.2 per 1,000 person years, rising to 16.9 and 19.5 per 1,000 person years in men and women aged >80 years, respectively [6]. Recent studies on syncope in older patients have focussed on evidence-based approaches to syncope management within existing geriatric medicine departments [7], with only 10.4% of cases remaining unexplained. Others have described the needs for, and benefits of, rapid access syncope clinics [8, 9]. However, few have focussed upon the applicability of these units in older age groups, where studies have suggested that the importance of making a correct diagnosis may be higher and management particularly challenging with the concomitant high prevalence of comorbidity and polypharmacy [10, 11]. Furthermore, older patients have a higher incidence of cardiac causes of syncope requiring a high index of suspicion and additional expertise [3]. Some authors [8, 9] suggest that rapid access syncope services should ideally be led by either cardiologists or neurologists without mention of the potential role of geriatricians in delivering these important services [11]. Despite the holistic view inherent in geriatric medical practice, there are relatively few data to support the role of geriatricians in running such services. Here, we describe our experiences of a rapid access syncope service led by geriatricians and specifically aimed at investigating and managing syncope in older people. The Newcastle Rapid Access Falls and Syncope Service (FASS) provides a service for adults of all ages who present with syncope and/or falls with the addition of particular expertise in the evaluation of older patients with comorbidity. FASS uses an assessment model based upon national [5, 12] and international [3, 13–15] guidelines and is a rapid access multidisciplinary approach to referrals with syncope. Patients are seen on the ‘see, assess, treat and triage’ model with as many investigations as possible completed at the initial ‘one-stop shop’ assessment. All patients have an initial detailed history and clinical examination by a geriatrician or primary care physician with extensive training and experience in the investigation and management of syncope. All then undergo 12-lead surface electrocardiography (ECG) and morning orthostatic blood pressure (BP) measurements per previously published protocols in addition to standard biochemical and haematological profiles. Falls risks are identified and treated per published guidance [15, 16]. If diagnostic uncertainty remains, patients undergo bilateral supine and erect carotid sinus massage, and if non-diagnostic, 20/15 glyceryl trinitrate provoked head-up tilt testing with continuous ECG and BP monitoring (to exclude vasovagal syncope) [12, 18]. Per our routine practice [5, 12] and international guidelines [3, 17], selected patients undergo ambulatory ECG (both 24-h and prolonged external loop) and BP monitoring. Further investigations are guided by history, clinical and surface ECG findings and include echocardiography, electroencephalography, electrophysiology studies and implantable loop recording per published guidelines [3, 17]. All patients are seen within 1–3 weeks of referral depending on need. Clinical information is recorded on a central database with written permission of patients. This is anonymously stored with permission from the Caldicott Guardian and Data Protection Officer from our institution for use for audit and service development. Details of this database have been published elsewhere [19]. Consecutive patients aged ≥65 years referred with syncope and seen in the FASS in 2007 were retrospectively identified from the database. Demographic data, investigations, time to diagnosis and ultimate diagnosis were reviewed in all cases from both the database and medical notes. In line with recent descriptions of syncope services across all age groups, ultimate diagnosis was broadly grouped into cardiac, non-cardiac, neurological, psychological and unexplained [1, 2]. Details of time of initial assessment in the FASS and time to diagnosis were determined from review of the database and medical notes. In 2007, the Newcastle Rapid Access FASS saw 180 new patients aged ≥65 years who presented for the first time with loss of consciousness. The mean age of this group was 77 SD (7.6) [range 65–97]. When classified according to the recommended criteria, only 7.5% of the total group referred with blackouts remained undiagnosed at the time of census. The majority of patients were found to have a blood pressure cause for their symptoms (Table 1), with 37% (66/180) of the total group of >65-year-olds presenting with blackouts having a diagnosis of vasovagal syncope. Diagnostic categories of older patients attending a specialist syncope service for older people PPM, permanent pacemaker. Diagnostic categories of older patients attending a specialist syncope service for older people PPM, permanent pacemaker. There was no difference between these diagnostic groups in terms of age at presentation or sex. Importantly, the principal diagnosis in 11% of the patient group was related to gait and balance abnormalities and falls, abnormalities that might not be conventionally considered as part of the routine assessment performed by those seeing patients with blackouts. Although the time to diagnosis was considerable in some patients (Figure 1), there were differences between the diagnostic groups, with time to diagnosis being longer in the group found to have a cardiac cause for their symptoms and quickest in the group presenting with falls, though this difference did not reach statistical significance (Figure 1). Number of weeks to diagnosis for each of the diagnostic categories for patients attending a specialist rapid access syncope service for older people. HR, cardiac group; BP, non-cardiac/blood pressure group; NEURO, neurological. Our results show the benefits of the Newcastle model for the investigation and management of syncope in older individuals. The comprehensive, multidisciplinary nature of our service clearly pays dividends in terms of the number of diagnoses made in our patients, with a 92.5% diagnostic rate. Conventional services in all ages report positive diagnostic rates between 60 and 90%, with up to 40% of older patients undiagnosed despite extensive investigation [6, 20–22], though Ungar and colleagues [7] report a similar diagnostic rate in geriatric in- and out-patient settings. Similar diagnostic rates in patients with unexplained drop attacks have been reported [19]. It is important to note the importance of a comprehensive falls assessment in this patient group given the overlap in presentation between falls and syncope [23]. There are several key differences in our service compared to many others [1, 3, 9, 24]. The first is that our falls and syncope service is run by clinicians with a specific interest and expertise in the multidisciplinary needs of older people. We believe that this is a significant benefit when compared to similar services run by single-organ specialists in, for example, cardiology and neurology. Secondly, our service is physician-led; some syncope services, particularly in the UK, are led by triage nurses. It is possible that adoption of a nurse-led service is related to a perception that this will be better value for money. Recent studies examining nurse-led endoscopy clinics suggest that this may not be the case [25]. In addition, while there is a vital role for allied professionals in syncope services for all age groups, it is particularly important that older patients have a thorough medical review as part of the evaluation process, given their atypical presentations [26], complex comorbidity and polypharmacy. The comprehensive medical and geriatric medical evaluation all our older patients receive in tandem with an evidence-based approach to syncope investigation [3, 12] is the keystone of our service and the source of our high diagnostic rate. We believe that this is important because of the significant morbidity [4] and mortality [27] associated with syncope in older people. Adopting the Newcastle Rapid Access FASS clinic model may also have financial benefits. Our unit has previously demonstrated dramatic reductions in bed days per year for the diagnostic categories comprising syncope and collapse, compared to other teaching hospitals in the UK [10]. This translates into significant savings in emergency hospital costs. Vasovagal syncope is an important diagnosis to consider in older people, and often presents atypically, making a diagnosis based on history, clinical examination and basic investigations more difficult than in younger patients [26]. We have a low threshold for tilt table testing in the appropriate context [12], which may account for our high diagnostic yield. Our reliance upon symptom reproduction in tandem with characteristic haemodynamic changes is vital in this context and effectively excludes false positivity as the source of our high diagnostic rate. Tilt table testing may be under-utilised in other syncope units. In our cohort of older patients with syncope, there were considerable numbers of non-syncope-related symptoms such as falls and gait and balance abnormalities. While these are clearly not causes of true syncope per the definition above, older patients may present with non-specific ‘collapse’ or ‘blackouts’, which with further multidisciplinary assessment have different root causes than an initial non-specialist review might suggest. It might be argued that geriatricians are less likely to diagnose cardiological or neurological abnormalities in those presenting with blackouts. This seems unlikely given that our figures are comparable to those from previously published data from a range of centres [7]. This suggests that blackout specialists with a geriatric medical background do not miss the cardiological and neurological disorders but do pick up a wide range of complex problems including falls and syncope risk factors including visual and cognitive impairment and gait disorders. As a result, our service is value added, providing high-quality, evidence-based patient-centred care. The comprehensive, multidisciplinary syncope service for older people has high diagnostic rates. Vasovagal syncope is a frequent cause of blackouts in older people. Syncope services led by geriatricians have advantages for older people. None of the authors has any conflict of interest. All authors have read and approved the final version of this manuscript.