Cognitive Impairment Is Very Common in Elderly Patients With Syncope and Unexplained Falls

Head-up tilt testing in older syncope patients: a systematic review

BACKGROUND

In older syncope patients, medical histories are often less reliable due to retrograde amnesia and cognitive impairment. Therefore, additional tests may be needed to reach a diagnosis. We conducted a systematic review to evaluate positivity rates and safety of head-up tilt testing (HUTT) in these patients.

METHODS

We searched Medline and Embase for HUTT positivity rates and diagnoses in older syncope patients (mean age ≥ 65 years) vs. younger patients. Secondary outcomes were time to syncope (TtS) and adverse events (AEs). Risk of bias was assessed with a modified version of the QUADAS-2.

RESULTS

In total, 42 studies were included, with 12 378 older participants in total. Positivity rates varied widely [passive HUTT 0.0%-90.0%; isoproterenol (IPR)-HUTT 18.3%-64.0%; nitroglycerin-HUTT 30.1%-90.5%]. The majority of studies found no differences between older and younger patients. Specificity was high for all HUTT-protocols (85.5%-100%). TtS did not differ between older and younger patients, but was significantly longer in control subjects. Nitroglycerin-HUTT yielded the most diagnoses (median 64.2% vs. 23.7% for passive, P = .007, and 44.8% for IPR-HUTT, n.s.). Vasodepressive responses were more common than cardioinhibitory responses (median 54.9% vs. 9.1%) in older patients. AEs occurred in <6% of patients with passive/nitroglycerin-HUTT.

DISCUSSION/CONCLUSION

There is no consistent evidence that HUTT results differ between older and younger syncope patients. Nitroglycerin-HUTT yields the most diagnoses, whilst retaining a high specificity, and is safe to perform in older patients. Future studies should focus on the additional value of HUTT on top of the initial evaluation in these patients.

Predicting postoperative delirium after hip arthroplasty for elderly patients using machine learning

BACKGROUND

Postoperative delirium (POD) is a common and severe complication in elderly hip-arthroplasty patients.

AIM

This study aims to develop and validate a machine learning (ML) model that determines essential features related to POD and predicts POD for elderly hip-arthroplasty patients.

METHODS

The electronic record data of elderly patients who received hip-arthroplasty surgery between January 2017 and April 2021 were enrolled as the dataset. The Confusion Assessment Method (CAM) was administered to the patients during their perioperative period. The feature section method was employed as a filter to determine leading features. The classical machine learning algorithms were trained in cross-validation processing, and the model with the best performance was built in predicting the POD. Metrics of the area under the curve (AUC), accuracy (ACC), sensitivity, specificity, and F1-score were calculated to evaluate the predictive performance.

RESULTS

476 Arthroplasty elderly patients with general anesthesia were included in this study, and the final model combined feature selection method mutual information (MI) and linear binary classifier using logistic regression (LR) achieved an encouraging performance (AUC = 0.94, ACC = 0.88, sensitivity = 0.85, specificity = 0.90, F1-score = 0.87) on a balanced test dataset.

CONCLUSION

The model could predict POD with satisfying accuracy and reveal important features of suffering POD such as age, Cystatin C, GFR, CHE, CRP, LDH, monocyte count, history of mental illness or psychotropic drug use and intraoperative blood loss. Proper preoperative interventions for these factors could reduce the incidence of POD among elderly patients.

Regression-Based Normative Data for the Montreal Cognitive Assessment (MoCA) and Its Memory Index Score (MoCA-MIS) for Individuals Aged 18-91

(1) Background: There is a need for a brief assessment of cognitive function, both in patient care and scientific research, for which the Montreal Cognitive Assessment (MoCA) is a psychometrically reliable and valid tool. However, fine-grained normative data allowing for adjustment for age, education, and/or sex are lacking, especially for its Memory Index Score (MIS). (2) Methods: A total of 820 healthy individuals aged 18-91 (366 men) completed the Dutch MoCA (version 7.1), of whom 182 also completed the cued recall and recognition memory subtests enabling calculation of the MIS. Regression-based normative data were computed for the MoCA Total Score and MIS, following the data-handling procedure of the Advanced Neuropsychological Diagnostics Infrastructure (ANDI). (3) Results: Age, education level, and sex were significant predictors of the MoCA Total Score (Conditional R2 = 0.4, Marginal R2 = 0.12, restricted maximum likelihood (REML) criterion at convergence: 3470.1) and MIS (Marginal R2 = 0.14, REML criterion at convergence: 682.8). Percentile distributions are presented that allow for age, education and sex adjustment for the MoCA Total Score and the MIS. (4) Conclusions: We present normative data covering the full adult life span that can be used for the screening for overall cognitive deficits and memory impairment, not only in older people with or people at risk of neurodegenerative disease, but also in younger individuals with acquired brain injury, neurological disease, or non-neurological medical conditions.

Risk Factors and Prognostic Follow-Up of Vasovagal Syncope Children With Seizure-Like Activities During Head-Up Tilt Test Induced-Syncope

Objectives

To analyze the risk factors associated with seizure-like activities during head up tilt test (HUTT)-induced syncope in children with vasovagal syncope (VVS) and assess the prognosis of these patients.

Methods

This is a retrospective study. VVS children with or without seizure-like activities during HUTT-induced syncope were included in convulsive or non-convulsive group. The clinical characteristics, hemodynamic parameters during HUTT-induced syncope and follow-up data were reviewed from the HUTT case report form and analyzed.

Results

68 cases (25 males, mean age 11.86 ± 3.35 years) were enrolled in convulsive group and 65 cases in non-convulsive group (24 males, mean age 11.64 ± 2.11 years). There were statistical differences in history duration, response type, and asystole between the two groups (all P < 0.05). Fully adjusted logistic regression showed that the risk of seizure-like activities was increased by 37.18 folds for patients with asystole compared with those without asystole (P = 0.005), by 308.25 and 6.08 folds for patients with cardioinhibitory type or mixed type compared with vasoinhibitory type (P < 0.01). No significant difference was exhibited in negative HUTT conversion rate and the proportion of re-syncope patients between the two groups at follow-up (both P > 0.05). None of these convulsive patients underwent pacemaker implantation during follow-up.

Conclusions

Asystole and response type were independent risk factors associated with seizure-like activities. Patients with asystole and mixed or cardioinhibitory responses to HUTT should be closely concerned. However, VVS children with seizure-like activities did not have a poor prognosis at follow-up.

The Syncope-Falls Index: a tool for predicting risk of syncope and complex falls in the older adult based on cumulative health deficits

BACKGROUND

Syncope is aetiologically diverse and associated with adverse outcomes; in older people, there is clinical overlap with complex falls presentations (i.e. recurrent, unexplained and/or injurious).

AIM

To formulate an index to predict future risk of syncope and falls in the Irish longitudinal study on ageing (TILDA).

DESIGN/METHODS

Using the frailty index methodology, we selected, from TILDA Wave 1 (2010), 40 deficits that might increase risk of syncope and falls. This syncope-falls index (SYFI) was applied to TILDA Wave 1 participants aged 65 and over, who were divided into three risk groups (low, intermediate and high) based on SYFI tertiles. Multivariate logistic regression models were used to investigate, controlling for age and sex, how SYFI groups predicted incident syncope, complex falls and simple falls occurring up to Wave 4 of the study (2016).

RESULTS

At Wave 1, there were 3499 participants (mean age 73, 53% women). By Wave 4, of the remaining 2907 participants, 185 (6.4%) had reported new syncope, 1077 (37.0%) complex falls and 218 (7.5%) simple falls. The risk of both syncope and complex falls increased along the SYFI groups (high risk group: odds ratio 1.88 [1.26-2.80], P = 0.002 for syncope; 2.22 [1.82-2.72], P < 0.001 for complex falls). No significant relationship was identified between SYFI and simple falls.

CONCLUSION

The 6-year incidences of falls and syncope were high in this cohort. SYFI could help identify older adults at risk of syncope and complex falls, and thus facilitate early referral to specialist clinics to improve outcomes.

Cognitive Screening in Geriatric Patients with Atrial Fibrillation Evaluated for Falls

Background

Atrial fibrillation (AF) is associated with cognitive decline and dementia. This study investigates whether the Montreal Cognitive Assessment (MoCA) detects more cognitive decline than the Mini Mental State Examination (MMSE) in patients with AF. Secondary aims were to assess the rate of white matter hyperintensities (WMH) and mesotemporal atrophy (MTA) in patients with AF.

Methods

Observational cohort study. Patients of 65 years and older that visited the Fall and Syncope Clinic were eligible. Patients were included if both a MoCA and MMSE were completed. In patients of whom an MRI was performed WMH were assessed with the Fazekas score and MTA was assessed with the MTA score. To assess frailty a Frailty Index (FI) was calculated.

Results

428 patients were included. Mean age was 80 years, 66% was female. The mean FI was 0.28 (CI 0.11 to 0.45), indicative of severe frailty. In 90 patients AF was known and in 9 patients it was first diagnosed, overall prevalence 23%. Cognitive impairment was found with the MoCA in 80% of patients with persistent AF, versus in 33% with the MMSE. Patients with paroxysmal AF had more WMH than patients with SR (p 0.04). No differences were found in relevant MTA between patients with AF or SR.

Conclusions

Cognitive decline in patients with AF is better detected using the MoCA than the MMSE. This means that in daily clinical practice, the MOCA should be used instead of the MMSE for patients with AF.

Progressive Resistance and Balance Training for Falls Prevention in Long-Term Residential Aged Care: A Cluster Randomized Trial of the Sunbeam Program

BACKGROUND

Falls prevention is an international priority, and residents of long-term aged care fall approximately 3 times more often than community dwellers. There is a relative scarcity of published trials in this setting.

OBJECTIVES

Our objective was to undertake a randomized controlled trial to test the effect of published best practice exercise in long-term residential aged care. The trial was designed to determine if combined high level balance and moderate intensity progressive resistance training (the Sunbeam Program) is effective in reducing the rate of falls in residents of aged care facilities.

METHOD

A cluster randomized controlled trial of 16 residential aged care facilities and 221 participants was conducted. The broad inclusion criterion was permanent residents of aged care. Exclusions were diagnosed terminal illness, no medical clearance, permanent bed- or wheelchair-bound status, advanced Parkinson's disease, or insufficient cognition to participate in group exercise. Assessments were taken at baseline, after intervention, and at 12 months. Randomization was performed by computer-generated sequence to receive either the Sunbeam program or usual care. A cluster refers to an aged care facility.

INTERVENTION

The program consisted of individually prescribed progressive resistance training plus balance exercise performed in a group setting for 50 hours over a 25-week period, followed by a maintenance period for 6 months.

OUTCOME MEASURES

The primary outcome measure was the rate of falls (number of falls and days followed up). Secondary outcomes included physical performance (Short Physical Performance Battery), quality of life (36-item Short-Form Health Survey), functional mobility (University of Alabama Life Space Assessment), fear of falling (Falls Efficacy Scale International), and cognition (Addenbrooke's Cognitive Evaluation-revised).

RESULTS

The rate of falls was reduced by 55% in the exercise group (incidence rate ratio = 0.45, 95% confidence interval 0.17-0.74); an improvement was also seen in physical performance (P = .02). There were no serious adverse events.

CONCLUSION

The Sunbeam Program significantly reduced the rate of falls and improved physical performance in residents of aged care. This finding is important as prior work in this setting has returned inconsistent outcomes, resulting in best practice guidelines being cautious about recommending exercise in this setting. This work provides an opportunity to improve clinical practice and health outcomes for long-term care residents.

Outcomes of Patients With Syncope and Suspected Dementia

OBJECTIVES

Syncope and near-syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short-term outcomes of patients who presented to the ED with syncope or near-syncope and were assessed by their ED provider to have dementia.

METHODS

This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near-syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient-level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death.

RESULTS

Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac-related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days.

CONCLUSIONS

Patients with perceived dementia who presented to the ED with syncope or near-syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal-concordant care is warranted.