Sincope e demenza nell anziano

Transcription

1 Stiamo lavorando per farti invecchiare meglio Napoli, 30 novembre/2 dicembre 2016 Simposio SIGG-GIMSI (Gruppo Italiano Multidisciplinare Sincope) LA SINCOPE NELL ANZIANO: dalle novitá fisiopatologiche alle peculiaritá cliniche Sincope e demenza nell anziano Prof. P. Abete Dipartimento di Scienze Mediche Traslazionali Università di Napoli Federico II

2 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

3 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

4 orthostatic hypotension reflex syncope NCVI hypothesis Neuro- CardioVascular Instability carotid sinus hypersensitivity postprandial hypotension Cognitive impairment DEMENTIA O Callagan S & Kenny RA, YJBM 2016

5 Hospitalization in Community-Dwelling Persons with Alzheimer s Disease: Frequency and Causes 25% % Fall Heart Disease Disease Rudolph JL et al., J Am Geriatr Soc, 2010

6 Prevalence (%) Prevalence of syncope and prodromic symptoms stratified for age Prodromic symptoms No Yes 60 75% >89 All (years) Galizia G et al., JAGS 2009

7 Age-related difference of amnesia for loss of consciousness is common in vasovagal syncope p<0.001 < 60 yr 60 yr p=0.003 % O Dwyer C et al.,europace 2011

8 Risk of permanent brain injury during syncope A person suffering from shock and hypotension should immediately be laid flat on the floor or horizontal to improve blood flow to the brain. It has been my experience that those who encounter an unconscious individual slumped in a chair with continued respiration; a weak, thready pulse; and hypotension may delay laying the person flat. A delay is especially likely in a nursing home if a resident is sitting in a wheelchair off his or her nursing unit. JAGS, 2009

9 Neuro- Cardiovascular Instability Emergency room admission DEMENTIA SYNCOPE Anamnesis unlikely Atypical presentation

10 Gruppo Italiano Multidisciplinare per lo Studio della Sincope Società Italiana di Gerontologia e Geriatria

11 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

12 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

13

14 SYNCOPE-DEMENTIA study Ungar A - Florence Mussi C - Modena Nicosia F - Gussago (BS) Bellelli G - Monza Bo M - Torino Riccio D - Cagliari, Landi F, Rome Noro G, Trento Abete P, Naples SYD study, 2015

15 Syncope and Dementia (SYD) protocol - 1 STUDY COHORT Individuals aged 65 and older consecutively referred to various settings (Syncope units, units for Alzheimer s diagnosis, day hospitals, nursing homes,acute care units) between February 2012 and April 2015 INCLUSION CRITERIA -Diagnosis of dementia defined according to DSM IV and during the previous 3 months one or more episodes of transient loss of consciousness (T-LOC) of a suspected syncopal nature or of an unexplained fall. EXCLUSION CRITERIA previous evaluation for syncope and unwillingness inability of the individual or a legal caregiver to provide informed consent.

16 Syncope and Dementia (SYD) protocol - 2 Comprenhsive Geriatric Assessment ADL, MMSE, GDS (if MMSE > 16), CIRS History, physical examination, ECG, clinostatic and orthostatic arterial pressure measurements, carotid sinus massage in lying down position CARDIAC SYNCOPE - echocardiography, - 24-hour ECG - 24-hours BP monitoring - loop recorder NEUROMEDIATED SYNCOPE - carotid sinus massage in an upright position - head-up tilt testing potentiated by sublingual nitroglycerin

17 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

18

19 Clinical charactristics (n = 357) v v v 4 syncopal episodes last 3 years Ungar A et al., JAGS 2016

20 Comorbodities, n (%) % Ungar A et al., JAGS 2016

21 Type of dementia, n (%) % Ungar A et al., JAGS 2016

22 High prevalence of vascular and mixed dementia BIAS? % DEMENTIA Ungar A et al., JAGS 2016

23 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

24 Initial and final diagnoses in total population (n = 357) suspected syncope n=181 unexplained falls n=166 syncope and falls n=10 Syncope=72.2%! syncope n= % syncope n= % syncope n=9 90.0%

25 Cardiac syncope % 50%

26 Reflex syncope % 50%

27 Orthostatic syncope 50% %

28 Differential diagnosis of unexplained falls in dementia: results of Syncope & Dementia (SYD) registry Syncope Initial diagnosis of syncope final diagnosis of syncope Syncopal Fall Initial diagnosis of fall final diagnosis of syncope Not Syncopal Fall Initial diagnosis of fall final diagnosis of fall Mossello E et al., submitted 2016

29 Differential diagnosis of unexplained falls in dementia: results of Syncope & Dementia (SYD) registry Syncope vs. not Syncopal Fall OR (95% CI) p Prodromes 4.55 (2.09, 9.92) <0.001 Situational causes 2.63 (1.10, 6.29) Outpatient setting 2.35 ( ) Precipitants 1.29 (0.67, 2.46) MMSE 1.04 (0.98, 1.10) Benzodiazepines 0.35 (0.16, 0.74) Injuries 0.27 (0.15, 0.52) <0.001 Insulin 0.18 (0.05, 0.60) Mossello E et al., submitted 2016

30 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

31 Cardiovascular drugs, n (%) % 50%

32 Psicoactive drugs, n (%) % 50%

33 Patients taking neuroleptics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) or antidementia drugs are at higher risk of adverse drug reactions (ADRs). ADRs occurring in the context of drug drug interactions are serious.

34 CARDIOACTIVE drugs and Syncope multivariate analysys Sartans ACE-inhibitors Nitrates Beta-blockers Anti-arrhythmics Calcium-antagonists Diuretics Alpha-blockers Digitalis

35 Cardioactive drug-drug interactions and Syncope multivariate analysis ACE-i + Diuretics 1.50 ACE-i 1.42 Diuretics

36 Psychoactive drugs and Syncope multivariate analysis Memantine Cholinesterase-i Antipsychotic Antiparkinsonian Antidepressant Anticonvulsant Benzodiazepine

37 Psychoactive drug-drug interactions and Syncope multivariate analysis Memantina + Cholinesterase-i 3.2 Memenatine 2.12 Cholinesterase-i

38 LA SINCOPE NELL ANZIANO: dalle novità fisiopatologiche alle peculiarità cliniche Sincope e demenza nell anziano - Background - Syncope and Dementia (SYD) Study - Methods - Etiology - Diagnosis - Drugs - Conclusions

39 Conclusions Syncope in the elderly suffering from dementia can be evaluated and studied with a diagnostic and standardized procedure. Vascular dementia is the more common form of dementia in the elderly with syncope Orthostatic syncope is the most frequent form in elderly patients with dementia. Particular attention to cardio- and psycho-active drug, and so more to drug-drug interaction.