Clinicians should be able to offer appropriate assessment and treatment for individuals who have orthostatic syncope (OS), even those individuals with advanced age and cognitive impairment, researchers from Italy wrote in an editorial in the May issue of JAMDA. Even so, more knowledge is needed.
Dr. Alice Ceccofiglio, of Azienda Ospedaliero-Universitaria Careggi and University of Florence, and colleagues compared the results of three multicenter studies of patients who experienced syncope. “During recent years, syncope studies have included an increasing number of older subjects with multimorbidity,” they wrote. “Moreover, increasing awareness of pathophysiology allows today a more accurate differential diagnosis of this condition. Yet how syncope etiology changes with advancing age and increasing multimorbidity is still unclear.”
Specifically, Dr. Ceccofiglio and colleagues looked at the Evaluation of Guidelines in Syncope Study 2 (EGSYS-2), which included 671 individuals with syncope; the Gruppo Italiano Sincope (GIS), which involved 231 patients age 65 and older with syncope; and the Syncope and Dementia (SYD) registry, in which a diagnosis of syncope was confirmed in 242 individuals who mostly had vascular dementia and Alzheimer’s disease.
Orthostatic syncope was more common in older individuals and was the leading cause of syncope in older individuals with dementia. In addition, there are some key findings as to the etiology of orthostatic syncope in older individuals, namely:
Intensive blood pressure control is a major contributor. For example, drug-induced orthostatic hypotension was the most prevalent cause of syncope in older adults and 25% of all syncope diagnoses in the SYD population. Also, it caused one in five cases of orthostatic syncope and 5% of all the diagnoses in the GIS population.
The SYD found an association between OS and treatment with nitrates or a combination of angiotensin-converting enzyme inhibitors with diuretics or nitrates, suggesting that hypotensive therapies in an older population, especially those with dementia, might be necessary as well as a higher blood pressure target, the researchers said.
Other conditions warrant investigation as possible causes of OS. These include neurodegenerative diseases such as Parkinson’s disease; peripheral neuropathies such as those caused by diabetes; dehydration; malnutrition; and deconditioning. For example, the researchers pointed out, secondary dysautotonomia was the second most frequent cause of OS in the SYD population, followed by volume depletion and primary autonomic failure.
A causal relationship between orthostatic hypotension and dementia is controversial, even though both conditions often coexist. Still, orthostatic hypotension is a risk factor for cognitive impairment, the researchers said. One possible explanation is that hypotension leads to cerebral hypoperfusion which, in turn, may lead to cognitive decline.
“In conclusion, data from these large studies indicate that advanced age and cognitive impairment should not prevent clinicians from providing the patient with appropriate diagnostic assessment and treatment for syncope,” Dr. Ceccofiglio and colleagues said in their editorial. “Indeed, in older patients with syncope a thorough diagnostic assessment is able to identify specific causes in the vast majority of cases, thus potentially allowing for events recurrence. Particularly, the prevalence of orthostatic syncope increases with advancing age and dementia, and causes [of syncope], first of all polypharmacy, are often reversible, [making it] potentially amenable to treatment.”
Source: Ceccofiglio A, et al. Increasing prevalence of orthostatic hypotension as a cause of syncope with advancing age and multimorbidity [published online ahead of print March 26, 2019]. J Am Med Dir Assoc. doi: 10.1016/j.jamda.2019.01.149
Vitamin D and Depression
Individuals who have vitamin D deficiency are more likely to develop depression later in life, according to a longitudinal study in Ireland—one of two studies in the May issue of JAMDA to look at the link between vitamin D levels and depression.
As part of the Irish Longitudinal Study on Aging (TILDA), a population-based study of community-dwelling adults age 50 and older, Dr. Robert Briggs, of St James’s Hospital, Dublin, and colleagues looked at the relationship between vitamin D levels and depression at baseline, two years after baseline, and four years after baseline.
Analysis of frozen non-fasting total plasma and assessment with depression scales from the Centre for Epidemiological Studies showed that 466 out of 3,965 individuals (12%) had vitamin D deficiency, and 1,150 individuals (29%) had vitamin D insufficiency. Individuals who had vitamin D deficiency at baseline were 75% more likely to have vitamin D deficiency four years later, even after controlling for such factors as depressive symptoms at baseline, chronic disease, physical activity, and cardiovascular disease.
In a second study, Shuang Zheng, of University of Tasmania in Australia, and colleagues found that vitamin D3 supplementation and adequate vitamin D levels over 24 months may be beneficial for depressive symptoms in patients with knee osteoarthritis.
The researchers conducted a pre-specified secondary analysis of the Vitamin D Effect on Osteoarthritis, or VIDEO, study, a multicenter, randomized, double-blind, placebo-controlled trial, that looked at whether vitamin D supplementation among patients with knee osteoarthritis and vitamin D deficiency might have a beneficial effect on depressive symptoms.
The researchers randomized 413 individuals to receive a 1.25mg vitamin D capsule or placebo for 24 months and then assessed depressive symptoms using the Patient Health Questionnaire (PHQ-9). The prevalence of depression in knee osteoarthritis patients was 25.4% at baseline, the researchers said.
By 24 months, serum 25-(OH) D levels increased from 43.7 nmol/l to 84.5 nmol/l in those individuals who received the vitamin D3 supplement, while levels went from 43.8 nmol/L to 50.6 nmol/L in those who received the placebo, the researchers found. There was greater improvement among those who received the vitamin D3 supplement vs. those who received the placebo.
PHQ-9 scores also improved more in those participants who maintained vitamin D sufficiency between months 3 and 24 compared with those who did not maintain sufficiency.
Sources: Zheng S, et al. Effect of Vitamin D Supplementation on Depressive Symptoms in Patients With Knee Osteoarthritis [published online ahead of print November 3, 2018]. J Am Med Dir Assoc. doi: 10.1016/j.jamda.2018.09.006 Briggs R, et al. Vitamin D Deficiency Is Associated With an Increased Likelihood of Incident Depression in Community-Dwelling Older Adults [published online ahead of print November 20, 2018]. J Am Med Dir Assoc. doi: 10.1016/j.jamda.2018.10.006
Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.