1. Syncope and pre-syncope
Syncope:- sudden, transient loss of consciousness, due to reduced cerebral perfusion. The patient is unresponsive with loss of control.
Pre-syncope:- feeling of light-headiness that would lead to syncope, if corrective measures were not taken ( usually sitting, lying or hanging)
It is a major cause of morbidity in elderly population occurs in ½ of institutionalized patients. Account for 5% of hospital admission.
Causes:-
Vasovagal :- vagal stimulation for example in fears and bad news
Postural hypotension:- main causes dehydration, septicaemia, medication, autonomic in Diabetes and addison’s disease.
Carotid sinus hypersensitivity
Cardiovascular :- arrythmia and outlet obstruction e.g. Aortic stenosis.
Neurology:- TIA and stroke.
A major cause of morbidity on elderly, occur in 25% of institutionalised older people , and are recurrent in 1/3. risk increase with age and with presence of CVD . It accounts for 5% of hospital admission and many serious injuries e.g. Hip fractures

2. Assessment of syncope History:-
Situation:- was the patient standing (orthostatic hypotension),exercising(Ischemia or arrhythmia), eating9post prandial), Frightened or in pain( vasovagal).
Prodrome;- Was there any warning? Palpitation suggest arrhythmia, light headiness suggest any cause of hypotension, gustatory or olfactory aura suggest seizure, however association are not absolute; e.g. Arrhythmia often don’t cause palpitation.
Was there any LOC:- 30% will have amnesia of any transiet LOC.
Description of the attack:- by eye witness
Recovery period :- Long indicate epilepsy and shor cardiac cause .
EXAMINATION:-
INVESTIGATION:- Blood ,ECG,other IX

3. ORTHOSTATIC HYPOTENSION
Common condition about 20% of community indwelling people and 50% of institutionalised older people
Most marked after meal, high temperature, exercise, and at early morning as well as late night
Reduction in systolic BP of 20mmHg on standing
Reduction in systolic BP to less than 90mmHg on standing
Reduction in diastolic BP of 10mmHg
with symptoms.

4. ORTHOSTATIC HYPOTENSION Causes
Drugs, like vasodilators, diuretics, B- blockers, alpha blockers, and CCB
Dehydration and acute hemorrhage( acute loss of volume)
Septicemia
Prolonged hypertension
Autonomic failure (pure, diabetic, parkinsons)
Adrenal insufficiency
Chronic hypertension( dcrease baroreflex sensitivity and LV compliance).
Prolonged bed rest.

5. ORTHOSTATIC HYPOTENSION - THERAPY
Lifestyle measures
Stop offending drugs
Compression hosiery
Sympathomimetic vasoconstrictors - Midodrine, 2.5 mg tds (max 40mg daily) CI in IHD
Caffeine with meal or NSAID
Head up-tilt to bed
Erythropoietin or octreotide
Volume expansion – Fludrocortisone mg/daily, DDAVP 5-20mg nocte.

6. Postprandial Hypotension
Significant when associated with symptoms , and fall of BP of more than 20mmHg . Within 75 minutes of meal.
more severe in older people , those with OH and autonomic failure.
Diagnosis:- Measure BP before meal and 30/60 minutes after meal.
Treatment:- Avoid Hypotensive drugs and alcohol with meals. Reduce osmotic load meal so have more frequent meals small portions and low simple CHO, high fiber/water content. Caffiene, Flurodocortison, NSAID rarely needed.

7. VASOVAGAL SYNCOPE - MECHANISM
Upright posture, downward displacement of blood & venous pooling leading to:
Decreased ventricular filling & cardiac mechanoreceptor activation leading to:
Increased brainstem input & reduced sympathetic outflow & increased vagal tone
Resulting in vasodilatation & bradycardia syncope

8. CAROTID SINUS HYPERSENSITIVITY
Episoidic, symptomatic, bradycardia, and or hypotension, due to hypersensitive carotid baroreceptor reflex, resulting on syncope or near syncope. It is an important and treatable cause.
2% in healthy individual, and 35% of fallers above the age of 80 years.
Mechanism
Typical triggers are:- neck turning( looking up or around), tight collars, straining, meal, prolonged standing.
How to perform CSM:- on a tilt table with 70 degree, CPR facilities should be available, CI if recent MI/CVA and should not be performed if carotid bruit unless normal doppler USS. Warn patient of possible SE specially arrhythmia happens in patient on digoxin, and neurological symptoms , usually transiet and happens in 0.14%). , attach the patient to cardiac monitor with beat to beat BP, identify carotid sinus, 5-10 second message, look for a systole and hypotension.,

9. CAROTID SINUS HYPERSENSITIVITY
Carotid sinus massage for 5 seconds:
Cardio inhibitory: 3 second or more period of asystole
Vasodepressor: a 50mmHg fall in systolic blood pressure
Mixed response

10. CSH - THERAPY Cardio-inhibitory: permanent pacing
Vasodepressor: very difficult to treat, consider those therapies used for orthostatic hypotension

11. Dizziness
Full history ?dizziness, ?vertigo, Pre-syncope, mixed, unsteadiness, malaise or generalised weakness
Causes
Acute lybranthitis
Menieres disease
BPV
Causes of syncope and pre-syncope
Post Circulation infarction
Vertebrobasilar insufficiency
Anxiety and depression
Multifactorial

12. Vertebrobasilar insufficiency
functional impairment of the midbrian, cerebellum, or occipital cortex , symptoms include:-
Abrupt onset, recurrent dizziness or vertigo.
Nausea and or vomiting.
Ataxia
Visual disruption.
Dysarthria
Limb parasthesia
Causes:- Atherosclerosis of vertebral or cerebellar a, vertebral artery compression by cervical osteophytes secondary to OA, Obstructing tumour.
Investigation:- Risk of CVD, X-ray Cx spine, CT head or MRI, MRA or Doppler

13. Clinical senarios
64 years old, history of flu like illness 4 days ago, now presenting with dizziness, nausea, vomiting, and vertigo, he presented to you with fall 2 hours ago.
67 years old man lives alone , presented with nausea, vomiting, right sided weakness, and slurred speech, followed by falling on the floor. Past medical history of diabetes, glaucoma, cataract. Smokes 20 cig/ daily, drinks 5 units of ETOH. Medication:- glucophage, B- blockers eye drops.
80 years old , collapsed when he looked up. He suffers from severe OA of both knees. He has been falling many times in the past.

14. PATIENT ASSESSMENT FOR SYNCOPE
HISTORY
Situation in which syncope occurred
Posture at time
Preceding symptoms
Actual loss of consciousness
Subsequent symptoms
Eye witness account
Co-morbidity
Drug history

15. EXAMINATION Heart rate / rhythm Postural BP Carotid bruits
Carotid sinus massage
Presence of murmurs
Neurology: evidence of stroke, cerebellar signs, Parkinson’s Disease

16. INVESTIGATIONS Baseline bloods : anaemia, renal dysfunction, diabetes
12 lead ECG
Holter monitoring
Tilt testing : 80’ head up tilt for 45 minutes +/- GTN provocation.
CSM supine & 80’ head up tilt

17. Tilt Table Testing
Advise patient to avoid caffeine, large meals & alcohol prior to test
Omit cardiac drugs prior to test
Consent for the procedure
Lie flat on tilt table for 15 minutes
CSM Supine
Tilt for 30 minutes
If no events – carry out CSM when tilted
If no events – administer 2 puffs GTN sublingually & monitor for a further minutes depending on response

18. Life Example
66 lady from India, diabetic on metformin, presented with history of recurrent falls in the last 6 months. She also complained of generally feeling weak, tired, lost 7kg in the last 3 months with nausea and vomiting in the morning . O/E Bp Lying 130/80 Standing 100/60
76 years old , history of recurrent fall, with history
Of hypertension on amlodipine, and osteoarthritis of
Both knees. Last fall happened while searching for
a book in his library . O/E BP L/S normal , bilateral
Knee swelling, X-ray neck severe OA (previous film)

19. Life Examples
74 man , hypertensive on amlodipine ,and amiloride, and lisinopril also has history of bilateral knee OA with left sided TKR. Recently visited a surgeon for symptoms of BPH , started on Doxazocin 4mg . Presented with feeling light headed , dizzy, and followed by blackout and then fall.
77 old man , history of parkinson disease , presented with recurrent falls associated with feeling dizzy on standing up ,BP (L) 140/90 (S) 110/70

20. The End