Syncope and orthostatic hypotension in older adults

Obtain three histories: the person, witness and records. Establish whether consciousness was lost, posture, trigger, warning, pallor or cyanosis, movements, tongue injury, incontinence, duration and recovery. Brief myoclonic jerks do not prove epilepsy. Ask medication timing, meals, toileting, heat, hydration and previous events. Injuries can be the only evidence when amnesia obscures loss of consciousness.

Examine cardiovascular and neurological systems, hydration and injury. A 12-lead ECG is core and must be reviewed for conduction disease, long or short QT, pre-excitation, Brugada pattern, ventricular hypertrophy or ischaemia. Exertional, supine, abrupt or cardiac-history events require urgent ambulatory monitoring, echocardiography or specialist testing according to suspected mechanism.

Measure orthostatic physiology carefully. Rest supine for at least five minutes, record blood pressure and pulse, then repeat during standing at about one and three minutes and during symptoms. If standing is unsafe, adapt with specialist help. Delayed orthostatic hypotension may require longer measurement. Document symptoms, meals and medicines; one normal test does not exclude intermittent postural disease.

Classical orthostatic hypotension is a sustained systolic drop of at least 20 mmHg or diastolic drop of at least 10 mmHg within three minutes. In people with supine hypertension a larger systolic criterion may be considered by specialists. Pressure below 90 systolic or typical symptoms can be important even when the numerical fall is smaller. Repeat at the time symptoms usually occur.

Review volume, haemoglobin, renal and electrolytes, glucose and infection when indicated. Reconcile diuretics, vasodilators, nitrates, alpha-blockers, antidepressants, antipsychotics, dopaminergic and rate-limiting medicines. Reduce or retime against the original indication and monitor heart failure, angina, urinary symptoms and mental health rather than stopping indiscriminately.

Non-drug treatment includes explaining triggers, adequate fluid when heart and kidney status permit, cautious salt increase, smaller lower-carbohydrate meals for postprandial symptoms, avoiding heat and alcohol excess, slow rising and physical counter-pressure manoeuvres. Abdominal compression is often more effective than stockings but dexterity and carer burden determine feasibility. Elevate the head of bed for neurogenic supine hypertension.

Midodrine, an alpha-1 agonist, is considered for severe neurogenic orthostatic hypotension despite non-drug care. Dose during waking upright hours and avoid within four hours of bed. Check supine and standing pressure and urinary retention. Fludrocortisone is off-label and expands volume but often problematic in heart failure, renal disease, hypokalaemia and supine hypertension.

For recurrent unexplained syncope, select testing from phenotype. Ambulatory ECG duration should match event frequency; implantable monitors may be needed for infrequent high-concern events. Echocardiography follows suspected structural disease. Tilt testing can demonstrate reflex susceptibility. Carotid sinus massage is performed in a monitored specialist setting in selected people over 40, with contraindication review.

Assess function and fear after collapse. Physiotherapy addresses deconditioning and safe transitions; OT reviews bathing, toilet and night routes. Teach what to do during prodrome and how to summon help. Recurrent events may change capacity for independent medication, stairs and bathing, but restrictions should be proportional and reviewed.

Driving advice is part of treatment. The person must stop driving after relevant unexplained blackout and notify DVLA when required. Rules differ by cause, recurrence and Group 1 or 2 licence. Document advice and check current DVLA guidance rather than offering a guessed fixed interval.