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Experience of a rapid access falls and syncope service at a teaching hospital in Kuala Lumpur

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Med J Malaysia Vol 72 No 4 August 2017 203
INTRODUCTION
Falls represent major health care issues among the older
population and are the leading reasons for visits to the
emergency department. It has been reported that 30-60% of
community-dwelling older adults sustain at least one fall
each year.1Falls in older adults commonly result in serious
physical, psychological, social and economic consequences.
In addition to the commonly feared osteoporotic fractures
and subdural haematoma, the pathological fear of falling or
post-fall syndrome also leads to physical frailty from activity
avoidance and depression.2Furthermore, falls are also major
causes of institutionalisation among our older population.
The published literature consistently report an overlap
between falls and syncope.3-5 Syncope is defined as a transient
loss of consciousness associated with reduced postural tone
and spontaneous recovery. In the Framingham cohort, the
incidence of syncope is reported to be 6.2 per 1000 person-
years, and this increases rapidly with age.6Structured
approaches have been recommended for the investigation
both falls and syncope, with evidence for cost effectiveness
from reduced hospitalization and unnecessary
investigations.7, 8
Previously published studies into the evaluation of falls and
syncope in a specialist unit have only been conducted in
Europe and USA.7, 9 Our objective was, therefore, to report the
experience of a dedicated falls and syncope service in
Malaysia, a middle-income country in South-East Asia.
MATERIALS AND METHODS
The Falls and Syncope Service at the University of Malaya
Medical Centre (UMMC), Kuala Lumpur, Malaysia, was
established in 2014 with the intention of providing
integrated, rapidly accessible services for patients who
presented to primary care and the emergency department
following an index fall or syncopal event. The service was
provided by two cardiologists, one geriatrician, one medical
specialist, one medical officer and four medical laboratory
technicians trained in the investigations and management of
falls and syncope. The medical centre serves as a training
hospital for a large medical school, a tertiary referral hospital
and a local general hospital for the Petaling District, Lembah
Pantai and Seputeh with a catchment population exceeding
300, 000. Individuals aged 60 and over currently make up 7.5
% of the local population.10 Patients were referred to this
service through the emergency department, primary care
department and other specialty clinics and wards if they
presented with syncope, pre-syncope or falls based on
published management algorithms.11
The demographic characteristics and clinical information of
consecutive patients attending our service since its
establishment till December 2016 were collected in a falls and
syncope registry. Structured clinical history taking and
targeted physical examinations were conducted on each new
patient referred to the service, guided by an electronic
medical record system template (EMR®, UMMC, Malaysia).
Each patient was then investigated for orthostatic
hypotension (OH), carotid sinus hypersensitivity (CSH),
vasovagal syncope (VVS), and/or autonomic dysfunction
according to clinical indication. The indications for each test
would be described in the relevant sub-sections below. All
haemodynamic tests were performed using synchronised,
non-invasive, beat-to-beat blood pressure and
electrocardiograhy (ECG) monitoring (Taskforce®,
CNSystems, Austria). Verbal consent was sought for all
individual tests after detailed explanation of the procedure
and clinical rationale for the tests. All patient identifiable
records were retained within the hospital server. Missing
information inaccuracies within the dataset were
consolidated by interrogating existing hospital records and
extracted anonymously for the purpose of this study.
Active/Passive Stand
Individuals who reported symptoms during posture change
were investigated with an active or passive stand. Following
at least 10 minutes of supine rest, patients were then required
to rise to the standing position within 30 seconds with the
assistance of at least two members of staff to ensure safety.
Patients were immediately interrogated for the presence of
any symptoms and advised to report the occurrence of any
symptoms while standing. If a symptom was reported, the
patient would also be asked if it resembled any symptom they
experienced prior. Individuals who were unable to stand
independently or who had transfer difficulties were
investigated with a passive stand. This involved a 3-minute
Experience of a rapid access falls and syncope service at
a teaching hospital in Kuala Lumpur
Gan Sin Yin, MBBS1, Nor Izzati Saedon, MMed1,2, Sukanya Subramaniam, DipMLT1, Nor Fairuz Husna Alias,
DipMLT1, Siti Sakinah Mohd Nasir, DipMLT1, Noor Fatin Izzati Abu Hashim, DipMLT1, Imran Zainal Abidin,
MMed3, Chee Kok Han, MMed3, Jassie Teo Yeh Lin, MBBS4, Tan Maw Pin, MD1,2
1Falls and Syncope Service, Cardiorespiratory Laboratory, University of Malaya Medical Centre, Kuala Lumpur, 2Division of
Geriatric Medicine, Faculty of Medicine, University of Malaya Medical Centre, Kuala Lumpur, 3Division of Cardiology, Faculty
of Medicine, University of Malaya Medical Centre, Kuala Lumpur, 4Department of Medicine, Faculty of Medicine, University of
Malaya, Kuala Lumpur
ORIGINAL ARTICLE
This article was accepted: 13 June 2017
Corresponding Author: Tan Maw Pin
Email: mptan@ummc.edu.my
1-Experience00110_3-PRIMARY.qxd 8/28/17 4:51 PM Page 203
Original Article
204 Med J Malaysia Vol 72 No 4 August 2017
70o head-up tilt on a tilt table (as described in the next
section) after 10 minutes’ supine rest. Synchronized
continuous blood pressure and ECG recordings were obtained
throughout 10 minutes of supine rest and during the 3
minutes of standing.
The presence of initial orthostatic hypotension (IOH),
conventional orthostatic hypotension (COH), or delayed OH
(DOH) will be recorded according to consensus committee
definitions.12
Head-up Tilt-table Test
Those with unexplained falls or syncopal symptoms not
associated with posture change or cardiac syncope were
evaluated with a head-up tilt-table test (HUT). The HUT was
not always indicated, as individuals with isolated syncopal or
pre-syncopal episodes with clear prodromes and associated
symptoms were diagnosed clinically. Tilt-table tests were
conducted using one of two published protocols. The first line
protocol was the 20: 15 Italian protocol. Those who had a
negative 20: 15 HUT with compelling history for neurally-
mediated syncope or who were physically unable to tolerate
being tilted upright for 35 minutes were investigated with a
front-loaded glyceryl trinitrate (GTN) HUT test. Brief
descriptions are offered below as the protocols have been
described in detail elsewhere.13, 14
20: 15 “Italian Protocol”
The patient was first asked to assume the supine position on
a commercially available tilt-table with armrests and
footrests, with 1-2 pillows, for 10 minutes. The patient was
then secured to the tilt-table at the waist and thigh with
cushioned Velcro strips supplied by the manufacturers. The
patient was tilted to a head-up position at a 70o angle for 20
minutes. If positivity criteria as described below was not met,
400 µg sublingual GTN will be administered and the patient
remained at the HUT position for a further 15 minutes.
Front-loaded GTN tilt
Following 10 minutes’ supine rest, the patient was tilted to
the 70oHUT position. 800 µg GTN would be administered
sublingually immediately. The test would be discontinued at
20 minutes or when positivity criteria was reached.
The positivity criteria was defined as the reproduction of
symptom (usually syncope) in tandem with hypotension
and/or bradycardia/asystole characteristic of the vasovagal
response. Where haemodynamic changes occurred along
without symptom reproduction, the test was considered a
false positive test.13
Carotid Sinus Massage
Investigation with carotid sinus massage (CSM) was limited
to those aged 50 years and over with sudden, unexplained
falls or loss of consciousness with no obvious precipitant or
prodrome, or preceded by sudden neck movements. Carotid
sinus massage was avoided in those with established
cerebrovascular disease or known carotid stenosis. After 10
minutes’ supine rest, firm, longitudinal massage would be
applied on both carotid sinuses, located at a point of
maximal pulsation between the angle of the mandible and
superior border of the thyroid cartilage,13 for 10 seconds,
beginning on the right. This manoeuvre would first be
performed in the supine position, followed by a 70otilt on a
tilt-table with a foot plate.15 The positivity criteria was
achieved if asystole of at least 3 seconds and/or systolic blood
pressure reduction of 50 mmHg or greater was observed after
CSM.
Autonomic Function Test
Autonomic function tests would only be performed among
those with persistent, intractable OH or associated conditions,
such as Parkinson’s disease and diabetes mellitus, suggestive
of neurogenic OH. This was conducted using newer
computational tests as well as traditional challenge tests.16, 17
The additional advantage of the computer-dependent tests of
heart rate variability (HRV) and baroreflex sensitivity (BRS) is
that they can be used as biofeedback for treatment strategies
for OH and VVS.18
Heart Rate Variability. Heart rate variability (HRV) was
assessed during 10 minutes’ supine rest. The low frequency
(LF), high frequency (HF) and total power spectral density
(PSD) was derived from the 10 minutes’ continuous ECG
recordings with the autoregressive technique using the
commercially available software.19
Baroreflex Sensitivity. Baroreceptor sensitivity (BRS) was also
evaluated during 10 minutes’ supine rest using the sequence
method. Sequences where increases or decreases in heart rate
corresponded to decreases or increases in blood pressure over
three or more consecutive beats were detected automatically,
and the slope of change was determined in mmHg/ms.20
Valsalva Ratio. The ratio of between longest R-R interval
shortly after performing the Valsalva manoeuvre to the
shortest R-R interval was calculated. The Valsalva manoeuvre
was standardised by asking the patient to blow into a
mouthpiece at a pressure of 40 mmHg for 15 seconds in a
comfortable seated position.
Inspiratory to Expiratory Ratio. This test was conducted in the
supine position to minimise the risk of orthostatic symptoms.
The patient was instructed to inhale and exhale at a rate of
six breaths per minute. The average inspiratory to expiratory
(I/O) ratio was determined from the maximum and
minimum heart rates over three breath cycles.
30: 15 Ratio. This was obtained during an active or passive
stand by calculating the ratio of the longest R-R interval
around the 30th beat to the shortest R-R interval around the
15th beat after standing.
Postural Blood Pressure Drop. The difference between the
average systolic and diastolic blood pressure for 20 beats
before standing and the minimal systolic and diastolic blood
pressure during the active or passive stand were determined.
Isometric Contraction. The maximal diastolic blood pressure
response during sustained handgrip maintained at 30 % of
the maximum voluntary contraction using a handgrip
dynamometer for 3 minutes or up to the point of exhaustion
was recorded.
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Experience of a rapid access falls and syncope service at a teaching hospital in Kuala Lumpur
Med J Malaysia Vol 72 No 4 August 2017 205
Table I: Sociodemographics, Comorbidities and Medication Histories of Patients
Characteristics n = 205 (%) Mean (SD)
Age (Years), median (IQR) 75 (81-65) 70 (17)
Female Gender, n (%) 126 (62)
Comorbidities
Diabetes, n (%) 65 (32)
Heart disease, n (%) 50 (24)
Atrial fibrillation, n (%) 10 (5)
Hypertension, n (%) 113 (55)
Stroke, n (%) 31 (15)
Hypercholesterolaemia, n (%) 69 (34)
Asthma/COPD, n (%) 16 (8)
Parkinson’s disease, n (%) 7 (3)
Depression, n (%) 14 (7)
Hypothyroidism, n (%) 9 (4)
Dementia, n (%) 10 (5)
Osteoarthritis, n (%) 27 (13)
Osteoporosis, n (%) 17 (8)
Hearing problem, n (%) 15 (7)
Visual problem, n (%) 32 (16)
Medication Histories
Cardioactive Drugs, n (%) 112 (55)
ACE Inhibitors, n (%) 34 (17)
Angiotensin II Antagonists, n (%) 24 (12)
Beta-Blockers, n (%) 39 (19)
Alpha-Blockers, n (%) 12 (6)
Calcium Antagonists, n (%) 54 (26)
Diuretics, n (%) 24 (12)
Anti-anginal Drugs, n (%) 17 (8)
Psychoactive Drugs, n (%) 16 (8)
Antidepressants, n (%) 13 (6)
Antipsychotics, n (%) 6 (3)
Sedatives, n (%) 3 (2)
Anticonvulsants, n (%) 11 (5)
Antidiabetic Agents, n (%) 44 (22)
Insulin Preparations, n (%) 11 (5)
SD, standard deviation; IQR, interquartile range; COPD, chronic obstructive pulmonary disease; ACE, angiotensin converting enzyme
Table II: Presenting Symptoms and Precipitating Factors of Patients
Precipitating factors Dizziness Syncope Falls
(n = 92) (%) (n = 72) (%) (n = 130) (%)
Head turning, n (%) 15 (16) 1 (1) 10 (8)
Posture change, n (%) 54 (59) 21 (29) 52 (40)
Prolonged standing, n (%) 25 (27) 7 (10) 19 (15)
Lying flat, n (%) 7 (8) 3 (4) 7 (5)
Hot weather, n (%) 5 (5) 6 (8) 2 (2)
After meals, n (%) 7 (8) 10 (14) 10 (8)
Palpitation, n (%) 11 (12) 5 (7) 2 (2)
Chest pain, n (%) 2 (2) 2 (3) 0 (0)
Micturition, n (%) 4 (4) 5 (7) 4 (3)
Defecation, n (%) 2 (2) 5 (7) 6 (4)
Other, n (%) 7 (8) 7 (10) 10 (8)
Nineteen (9 %) patients report the presence all the three symptoms of dizziness, syncope and falls. Figure 2 showed the percentages of patients with
overlapping of symptoms
Table III: Diagnoses of Patients
Characteristics n = 205 (%) Dizziness Syncope Falls
(n = 92) (%) (n = 72) (%) (n = 130) (%)
Orthostatic hypotension, n (%) 53 (26) 33 (36) 16 (22) 43 (33)
Reflex syncope, n (%) 48 (23) 32 (35) 31 (43) 37 (28)
Vasovagal syncope, n (%) 44 (22) 29 (32) 30 (42) 34 (26)
Carotid sinus hypersensitivity, n (%) 5 (2) 3 (3) 3 (4) 5 (4)
Situational syncope, n (%) 2 (1) 1 (1) 1 (1) 2 (2)
Cardiac syncope, n (%) 8 (4) 3 (3) 5 (7) 5 (4)
Arrhythmia, n (%) 6 (3) 3 (3) 3 (4) 4 (3)
Others*, n (%) 47 (23) 29 (32) 8 (11) 42 (32)
* inclusive of multifactorial falls. Totals exceed 100% as more than one diagnosis may coexist in each individual.
1-Experience00110_3-PRIMARY.qxd 8/28/17 4:51 PM Page 205
Cold Pressor Test. The maximal diastolic blood pressure rise
was recorded while the free hand was immersed up to the
wrist in ice-cold water for 1 minute.
Data Analysis
Data analysis was performed using the SPSS Statistical
Package version 20.0. Normal distribution was determined by
visually inspecting histogram. Basic characteristics were
summarized in means with standard deviations or medians
with interquartile ranges in parenthesis or frequencies with
percentages for continuous and categorical variables
respectively.
RESULTS
Sociodemographics, comorbidities and medication histories
Two hundred and five patients were referred to the Falls and
Syncope Service over the 29-month period. The median age
(interquartile range) was 75 (65 to 81) years. Figure 1 showed
the age distribution of patients referred to the service with
bimodal peaks at 25-30 years and 75-80 years.
Two hundred and five patients were referred to the Falls and
Syncope Service over the 29-month period. The median age
(interquartile range) was 75 (65 to 81) years. Figure 1 showed
the age distribution of patients referred to the service with
bimodal peaks at 25-30 years and 75-80 years.
Presenting Symptoms and Precipitating Factors
One hundred and thirteen (55 %) patients reported
symptoms of dizziness and 72 (35 %) had one or more
episode(s) of syncope. One hundred and thirty (63 %) had
fall(s) and 52 (26 %) sustained injury(ies). Precipitating
factors with respect to the presenting symptoms were
summarised in table II. Forty-five individuals (22 %)
presented with symptoms of falls with no co-existing
symptoms of dizziness or syncope. These individuals were not
more likely to report precipitating factors of posture change
or prolonged standing compared to those with and without
falls with symptoms of dizziness and syncope (Odd ratio, OR
= 0.560, 95 % Confidence interval, CI = 0.269 to 1.165).
Diagnoses
The most common diagnosis was orthostatic hypotension (26
%), followed by reflex syncope (23 %) and cardiac syncope (4
%). Diagnoses with their respective presenting symptoms
were summarised in Table III. Individuals presenting with
falls alone without accompanying symptoms of dizziness or
syncope were not less likely to be diagnosed with orthostatic
hypotension, reflex syncope or cardiac syncope (OR = 0.629,
95 % CI = 0.322 to 1.227).
DISCUSSION
We have described the experience of a dedicated falls and
syncope service developed to conduct structured evaluation of
two closely associated and common medical conditions. The
majority of our patients were female and fell within the
elderly age group. Fifty-five percent patients had a pre-
existing diagnosis of hypertension and 55 % were also on
cardioactive drugs, while one-third were diabetics. Falls were
the commonest symptoms reported by patients referred to the
service, followed by dizziness and syncope, but an overlap
existed between the three symptoms, with 9% reporting the
presence of all three.
Bimodal peaks could be observed in the age distribution of
our patient with a sharp increase around the age of 70 years.
These findings were in tandem with those found in the
Framingham cohort.6This demonstrates that falls and
syncope are age-dependent conditions. The basic
demographics of our patients differ from those reported
previously by other similar services, with a much higher
preponderance of hypertension and diabetes.21 This suggests
the presence of regional variations characteristics of falls and
syncope, therefore limiting the applicability of current
published evidence which have been mainly generated from
Western Europe and North America.
The overlap between falls, syncope and dizziness
demonstrated in our study has been previously reported.22, 23
Falls and syncope are commonly managed as two separate
entities with syncope often considered a neurological or
cardiological condition while falls are often under-reported
Original Article
206 Med J Malaysia Vol 72 No 4 August 2017
Fig. 1: Age distribution of patients (n = 205). Fig. 2: Percentage of patients with dizziness, syncope, falls and
overlaps in presenting symptoms.
1-Experience00110_3-PRIMARY.qxd 8/28/17 4:51 PM Page 206
Experience of a rapid access falls and syncope service at a teaching hospital in Kuala Lumpur
Med J Malaysia Vol 72 No 4 August 2017 207
with the management often targeted solely at the resultant
injury which led to the presentation of emergency medical
services.24 Factors which deem falls and syncope
indistinguishable in the elderly were cognitive impairment,
poor recall of the event and a lack of witness accounts.3
Furthermore, amnesia for loss of consciousness is well-
documented in individuals with a subsequent diagnosis of
CSH or VVS presenting as unexplained falls.5, 25 Both falls and
syncope are also related to potentially avoidable escalating
healthcare expenditure in terms of hospitalization costs,
unnecessary investigations and institutionalization costs.26-28
Furthermore, robust evidence exists for the structured
evaluation and multidisciplinary approach for both
conditions.28, 29
The diagnosis of OH, reflex syncope and cardiac syncope
were made in 53 % of all attenders regardless of
presentations. When we considered only those with isolated
symptoms of falls with no accompanying symptom of
dizziness or syncope, these individuals were not less likely to
report precipitating symptoms of posture change or
prolonged standing and were not less likely to be diagnosed
with OH, reflex syncope or cardiac syncope. This has
important clinical implications, in that the absence of
dizziness and syncope in the individuals presenting with falls
does not exclude the diagnosis of hypotensive or bradycardic
disorders. Our findings are consistent with previous studies
involving individuals with unexplained falls, which
established the presence of amnesia of loss of consciousness
in individuals diagnosed with CSH and VVS.25
Approximately a quarter of our patients with any symptom
presentation was diagnosed with OH. The number of patients
with OH in our study was slightly higher as compared to
those found in the Evaluation of Guidelines in Syncope Study
2 conducted in Italy.30 This may be accounted for by age
differences, the much higher proportion of individuals with
diabetes and the higher use of cardioactive drugs among our
clients.31, 3 2 Diabetes is associated with autonomic
neuropathy, as well as hypertension and cardiovascular
diseases increasing the need for cardioactive drugs. Both
autonomic neuropathy and cardioactive medications are
associated with OH. A number of studies looking at the effect
of withholding fall-risk-increasing medications such as
psychotropic and cardiovascular drugs reported a symptom
improvement after stopping the medications.3 3, 34 The
presence of a falls and syncope service with structured
processes ensures the methodical documentation of
medications use and that healthcare personnel involved in
the service are trained in medication review. Furthermore,
careful targeted monitoring can also be ensured as
medication dose reduction and withdrawal are associated
with exacerbation of the underlying medical condition which
may then require finer dose adjustments or replacement with
alternative treatments.
The establishment of rapid access falls and syncope services
have been shown to improve the management of patients
presented with unexplained falls and syncope.7, 22, 35, 36 Our
experience has also demonstrated that such services can also
be adapted for a healthcare service based in a middle-income
Asian nation. The diagnosis of OH, reflex syncope or cardiac
syncope was achieved in 72 % of those presenting with
syncope, and 65-71 % of those with falls and dizziness
respectively as evidence of the effectiveness of a structured
approach achieving diagnostic yield comparable to that of
previous studies.22, 30 Our study was observational in nature,
with our patient mix reliant entirely on referral patterns by
primary care, trauma and emergency and other medical
specialties. The proportion of falls attributable to syncope
disorders may therefore be falsely high, as individuals
referred may be more likely to be suspected to suffer from
syncopal disorders. Our findings concerning the overlap
patterns between dizziness, falls and syncope will therefore
need to be confirmed in population based studies involving
representative samples. Future studies should also be directed
at assessment of the health economic implications of setting
up such unit in a middle-income country.
CONCLUSION
We have successfully established a falls and syncope service
in a busy teaching hospital based in Kuala Lumpur. The
majority of our patients exceeded the age of 65 years. The
symptoms of falls, syncope and dizziness overlapped in 40 %
of patients. The diagnostic yield of 72 % for patients with
syncope evaluated by our service is comparable to that of
similar services developed previously. Further research should
evaluate the suggested overlap in representative community
samples, and also seek to determine the cost-effectiveness of
the falls and syncope service in our middle-income country.
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