Feasibility, reliability and safety of self-assessed orthostatic blood pressure at home.

BACKGROUND: A postural blood pressure assessment is required to diagnose Orthostatic Hypotension. With increasing remote consultations, alternative methods of performing postural blood pressure assessment are required. OBJECTIVE: Determine whether postural blood pressure measurement at home, without a clinician, is reliable, feasible and safe. DESIGN: Service improvement project within a falls and syncope service in Northeast England. SUBJECTS: Eligibility criteria: aged ≥60 years; postural blood pressure measurement is indicated and is physically and cognitively able to perform. Exclusion criteria: nursing home residents, attending clinic in person. METHODS: Postural blood pressure measurements were performed in patients' homes under clinical observation. Patient-led assessments were performed independent of the clinician, following written guidance. This was followed by a clinical-led assessment after 10-minute supine rest. OUTCOMES: Agreement between patient and clinician derived postural blood pressure values and diagnosis of Orthostatic Hypotension; intervention safety, feasibility and acceptability. RESULTS: Twenty-eight patients were eligible and 25 participated (mean age 75, median Clinical Frailty Score five).There was 95% agreement (Cohen's kappa 0.90 (0.70, 1.00)) between patient and clinician derived readings to diagnose orthostatic hypotension.Postural systolic blood pressure drop correlated strongly (r = 0.80), with patient derived readings overestimating by 1 (-6, 3) mmHg. Limits of agreement, determined via Bland Altman analysis, were +17 and -20 mmHg, greater than pre-determined maximum clinically important difference (±5 mmHg).Twenty participants performed valid postural blood pressure assessments without clinical assistance. CONCLUSIONS: Patient-led postural blood pressure assessment at home is a reliable, safe and acceptable method for diagnosing Orthostatic Hypotension.

Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): an integrated, mixed-methods approach.

BACKGROUND: Falls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention. METHODS: The intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n = 81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n = 15) on the proposed model, the intervention was manualised and training developed. RESULTS: We identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient's home. CONCLUSIONS: A new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested. TRIAL REGISTRATION: ISRCTN41760734 (16/11/2015).

Feasibility of trial procedures for a randomised controlled trial of a community based group exercise intervention for falls prevention for visually impaired older people: the VIOLET study.

BACKGROUND: Visually impaired older people (VIOP) have a higher risk of falling than their sighted peers, and are likely to avoid physical activity. The aim was to adapt the existing Falls Management Exercise (FaME) programme for VIOP, delivered in the community, and to investigate the feasibility of conducting a definitive randomised controlled trial (RCT) of this adapted intervention. METHODS: Two-centre randomised mixed methods pilot trial and economic evaluation of the adapted group-based FaME programme for VIOP versus usual care. A one hour exercise programme ran weekly over 12 weeks at the study sites (Newcastle and Glasgow), delivered by third sector (voluntary and community) organisations. Participants were advised to exercise at home for an additional two hours over the week. Those randomised to the usual activities group received no intervention. Outcome measures were completed at baseline, 12 and 24 weeks. The potential primary outcome was the Short Form Falls Efficacy Scale - International (SFES-I). Participants' adherence was assessed by reviewing attendance records and self-reported compliance to the home exercises. Adherence with the course content (fidelity) by instructors was assessed by a researcher. Adverse events were collected in a weekly phone call. RESULTS: Eighteen participants, drawn from community-living VIOP were screened; 68 met the inclusion criteria; 64 participants were randomised with 33 allocated to the intervention and 31 to the usual activities arm. 94% of participants provided data at the 12 week visit and 92% at 24 weeks. Adherence was high. The intervention was found to be safe with 76% attending nine or more classes. Median time for home exercise was 50 min per week. There was little or no evidence that fear of falling, balance and falls risk, physical activity, emotional, attitudinal or quality of life outcomes differed between trial arms at follow-up. CONCLUSIONS: The intervention, FaME, was implemented successfully for VIOP and all progression criteria for a main trial were met. The lack of difference between groups on fear of falling was unsurprising given it was a pilot study but there may have been other contributory factors including suboptimal exercise dose and apparent low risk of falls in participants. These issues need addressing for a future trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN ID: 16949845 Registered: 21 May 2015.

New Horizons in orthostatic hypotension.

Background: orthostatic hypotension (OH) is a common disabling condition associated with increased morbidity and mortality. Much of the evidence available is derived from younger populations with chronic neurological disease leading to uncertainty for the diagnosis and management of older people. Objective: to provide an overview of recent and emerging evidence for the diagnosis, management and prognosis of OH in older persons. Methods: a narrative review of recent studies, emerging therapies and relevant regulatory updates. Findings: revisions to the diagnostic criteria for OH include the duration of the blood pressure drop, specific criteria for initial and delayed OH and OH with hypertension. Non-drug therapies remain the first-line treatment option and Comprehensive Geriatric Assessment appears to result in lower rates of OH. Recent evidence concerning withdrawal of causative medication is inconsistent. Midodrine has recently become the only licenced medication for OH in the UK. Other emerging treatments include atomoxetine and droxidopa but these require further evaluation. Many other agents may be used but are not supported by high-quality evidence. The increase in mortality associated with OH is less apparent in older people. Summary: OH remains common in older people, the new diagnostic criteria address some of the previous uncertainty but evidence concerning withdrawal of antihypertensives is conflicting. Midodrine is now the only licenced medication for OH in the UK, but non-drug therapies remain first line and fludrocortisone may be considered before midodrine. We may see other agents such as droxidopa becoming increasingly used over the coming years.

Does the falls efficacy scale international version measure fear of falling: a reassessment of internal validity using a factor analytic approach.

BACKGROUND: the Falls Efficacy Scale-International (FES-I) is a widely used measure of fear of falling that assesses concerns with respect to falls over a range of physical and social activities. In the original validation study, the methods used (self-selection by participants) were likely to over-represent those with a higher educational level and socio-economic grouping. In addition, the factor analysis method used was potentially less applicable to older individuals and may have been less likely to measure the construct of fear of falling. OBJECTIVE: to validate the internal validity of the FES-I and assess its suitability as a measure of fear of falling. DESIGN: cross-sectional survey. SETTING: community sample. METHODS: a random sample of 200 participants aged 60 years completed the FES-I by structured interview. We verify internal validity with a factor analytic approach not previously employed in this study design context, principal factor analysis on the matrix of polychoric correlations. RESULTS: we find no redundancy in the questions on the FES-I. All are found to strongly represent concerns about falling during social and physical activities. CONCLUSION: the FES-I is an appropriate tool to assess fear or concerns with respect to falls in the general elderly population, and more appropriately represents concern of falling than has previously been found. Future health services research with the FES-I should have its design informed by the results presented in this study, as the structure of the 'concern with falling' factor differs markedly from that found in previous validity testing.

Making sense of a cognitive behavioural therapy intervention for fear of falling: qualitative study of intervention development.

BACKGROUND: Fear of Falling (FoF) is commonly reported among older adults (up to 50%) and can impact negatively on physical and social activities, mood and quality of life. This paper explores the development, acceptability and feasibility of a cognitive behavioural therapy intervention (CBTi) for FoF. METHODS: The process evaluation of the CBTi development phase of an RCT (conducted in the UK) reported here, used ethnographic methods. Data included: interviews with patients and carers (n = 16), clinic staff (n = 6) and the psychologists developing the CBTi (n = 3); observational field notes and transcripts of intervention development meetings (n = 9) and stakeholder engagement meetings (n = 2); and informal discussions with staff developing the CBTi (n = 8). Data collection and thematic analysis were guided by Normalisation Process Theory (NPT). RESULTS: The process evaluation showed two domains of work necessary to develop a CBTi that made sense to stakeholders, and that could be delivered as part of an RCT. For the psychologists developing the content of the CBTi, a growing understanding of the complexity of FoF highlighted the need for an individualised rather than a manualised intervention. For the research team, the work involved adapting the structures and processes of the RCT to address preliminary concerns over the acceptability and feasibility of the proposed CBTi. CONCLUSIONS: Theory-based approaches to process evaluation can sensitise researchers to contested understandings about proposed interventions that could undermine implementation. Drawing on the coherence construct of NPT, this study emphasises the nature and extent of work required to ensure an intervention makes sufficient sense to key stakeholders in order to maximise chances of successful implementation.

Maintaining independence in individuals with dementia at home after a fall: a protocol for the UK pilot cluster randomised controlled trial MAINTAIN.

INTRODUCTION: Individuals with dementia face an increased risk of falls. Falls can cause a decline in the individual's overall functionality. All types of falls, including those that do not result in injury, can lead to psychosocial consequences, such as diminished confidence and a fear of falling. Projections indicate a rising trend in dementia diagnoses, implying an increase in fall incidents. Yet, there is a lack of evidence to support interventions for people living with dementia who have fallen. Our objective is to test the feasibility of a falls intervention trial for people with dementia. METHOD AND ANALYSIS: This is a UK-based two-arm pilot cluster randomised controlled trial. In this study, six collaborating sites, which form the clusters, will be randomly allocated to either the intervention arm or the control arm (receiving treatment as usual) at a 1:1 ratio. During the 6 month recruitment phase, each cluster will enrol 10 dyads, comprising 10 individuals with dementia and their respective carers, leading to a total sample size of 60 dyads. The primary outcomes are the feasibility parameters for a full trial (ie, percentage consented, follow-up rate and cost framework). Secondary outcomes include activities of daily living, quality of life, fall efficacy, mobility, goal attainment, cognitive status, occurrence of falls, carer burden and healthcare service utilisation. Outcome measures will be collected at baseline and 28 weeks, with an additional assessment scheduled at 12 weeks for the healthcare service utilisation questionnaire. An embedded process evaluation, consisting of interviews and observations with participants and healthcare professionals, will explore how the intervention operates and the fidelity of study processes. ETHICS AND DISSEMINATION: The study was approved by the NHS and local authority research governance and research ethics committees (NHS REC reference: 23/WA/0126). The results will be shared at meetings and conferences and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN16413728.

Comparing Research Priority-Setting Partnerships for Older Adults Across International Health Care Systems: A Systematic Review.

OBJECTIVES: Priority setting partnerships (PSPs) attempt to shape the research agenda to address the needs of local populations of interest. We reviewed the PSPs for older adults, with a focus on exemplar health care systems: United Kingdom (UK; publicly funded), United States (private health insurance-based), South Korea (national health insurance-based), and Africa (out-of-pocket). DESIGN: Systematic review. SETTING AND PARTICIPANTS: We searched databases and sources (January 2011-October 202l; updated in February 2023) for PSPs of older adults' health care. METHODS: Based on the British geriatric medicine curriculum, we extracted and categorized the PSP topics by areas and the research priorities by themes, and generated evidence maps depicting and comparing the research gaps across the systems. We evaluated PSP quality using the Nine Common Themes of Good Clinical Practice. RESULTS: We included 32 PSPs (United Kingdom: n = 25; United States: n = 7; South Korea and Africa: n = 0) and identified priorities regarding 27 conditions or service arrangements in the United Kingdom and 9 in the United States (predominantly in neurology/psychiatry). The UK priorities focused on treatments and interventions whereas the US on prognostic/predictive factors. There were notable research gaps within the existing PSPs, including common geriatric conditions like continence and frailty. The PSP quality evaluation revealed issues around lacking inclusion of ethnic minorities. CONCLUSIONS AND IMPLICATIONS: Research priorities for older adult health care vary internationally, but certain health care systems/countries have no available PSPs. Where PSPs are available, fundamental aspects of geriatric medicine have not been included. Future researchers should conduct prioritizations in different countries, focus on core geriatric syndromes, and ensure the inclusion of all relevant stakeholder groups.

Regional cerebral blood flow in late-life depression: arterial spin labelling magnetic resonance study.

BACKGROUND: A limited number of studies have demonstrated changes in cerebral blood flow (CBF) in older individuals with depression, but there are considerable inconsistencies between studies. AIMS: To investigate changes in CBF using arterial spin labelling (ASL) magnetic resonance imaging (MRI) in people with late-life depression and in a similarly aged healthy control group. METHOD: Sixty-eight participants (30 healthy individuals, 38 with depression) underwent ASL and T(1)-weighted MRI scanning. For each individual, regional estimates of separate grey and white matter CBF were obtained. Group differences in CBF and their associations with clinical features were examined. RESULTS: Significant increases were observed in white matter CBF in patients with depression relative to the control group (F(1,65) = 9.7, P = 0.003). Grey matter CBF in lateral frontal, medial frontal, cingulate, central and parietal regions did not significantly differ between groups (F(1,65)≤2.1, P≥0.2). A significant correlation was found between white matter CBF and Montgomery-Åsberg Depression Rating Scale (MADRS) scores in depression (r' = -0.42, P = 0.03). Further analyses revealed that compared with controls, significant elevation of white matter CBF was apparent in participants whose depression was in remission (n = 21, MADRS≤10, P = 0.001) but not in those with current depression (n = 17, MADRS≥11, P = 0.80). CONCLUSIONS: Findings suggest a compensatory response to white matter pathological change or a response to (or a predictor of) successful antidepressant treatment, perhaps by facilitating neurotransmission in specific circuits and so reducing depressive symptoms.

Is fear of falling key to identifying gait and balance abnormalities in community-dwelling older adults? Protocol of a mixed-methods approach.

INTRODUCTION: The ageing population poses an increasing burden to public health systems, particularly as a result of falls. Falls have been associated with poor gait and balance, as measured by commonly used clinical tests for poor gait and balance. Falls in older adults have the potential to lead to long-term issues with mobility and a fear of falling (FoF). FoF is measured by a variety of instruments; the Falls Efficacy Scale International (FES-I) version is widely used within clinical and research arenas. The ability of the FoF, as measured by the FES-I to predict gait and balance abnormalities (GABAb) has not previously been measured; this study aims to be the first to investigate this prospective relationship. METHODS AND ANALYSES: To investigate the ability of the FES-I to predict GABAb a mixed-methods approach will be used, including quantitative, qualitative and health economics approaches. Initially the ability of the FES-I to identify poor gait and balance will be investigated, along with whether the measure is able to assess change in gait and balance in response to exercise training. The ability of an online FES-I tool to assess poor gait and balance in an alternative pre-existing online strength and balance programme will also be investigated. Interviews will be carried out to investigate participant experiences and motivations of those that are offered Age UK Strength and Balance Training, along with the views of healthcare professionals and Age UK staff involved within the process. ETHICS AND DISSEMINATION: NHS REC Approval has been granted (IRAS ID 314705). Study participation is voluntary; participants will be provided with all necessary information within the participant information sheet, with written consent being sought. Study findings will be disseminated through manuscripts in peer-reviewed journals, at scientific conferences and in a short report to participants and the funding body.

Relationship of orthostatic blood pressure to white matter hyperintensities and subcortical volumes in late-life depression.

BACKGROUND: Structural brain abnormalities are associated with late-life major depression, with numerous studies reporting increased white matter hyperintensities (WMH) and reduced cortical/subcortical grey matter volumes. There is strong evidence linking vascular disease to WMH, but limited evidence on its association with subcortical volumes. AIMS: To investigate the relationship of orthostatic blood pressure changes to WMH and subcortical grey matter volumes in late-life depression. METHOD: Thirty-eight people with depression and a similarly aged comparison group (n = 30) underwent fluid attenuated inversion recovery (FLAIR) and T(1)-weighted magnetic resonance imaging as well as systematic orthostatic blood pressure assessments. Volumetric estimates of WMH and subcortical grey matter were obtained for each participant and the relationship to blood pressure drop on active stand was examined. RESULTS: An association between orthostatic systolic blood pressure drop and WMH volumes in temporal and parietal regions was found in the depression group (age-corrected partial correlation r' = 0.31-0.35, P<0.05). Subcortical volumes were not related to blood pressure changes or WMH volumes in either group. CONCLUSIONS: We found evidence for an association between the degree of orthostatic systolic blood pressure drop and WMH volume in the depression group. Since blood pressure drops lead to WMH in animals our findings suggest systolic blood pressure drops may be a factor contributing to these lesions in late-life depression.

The history of diagnosing carotid sinus hypersensitivity: why are the current criteria too sensitive?

The carotid sinus syndrome and carotid sinus hypersensitivity (CSH) are closely related disorders. The first is characterized by syncope triggered by manipulation of the carotid sinus in daily life (e.g. shaving). According to the current European Society of Cardiology guidelines, CSH is diagnosed when carotid sinus massage elicits ≥3 s asystole, a fall in systolic blood pressure of ≥50 mmHg, or both, with symptoms. The question is, however, whether symptoms can be expected when these criteria are met. Although they are widely accepted, we will show that their basis is primarily in arbitrary clinical observations and that in the original publications the link between classification and clinical symptoms was often dubious. The current criteria for CSH are thus too sensitive, explaining the reported high prevalence of CSH in the general older population. The review will conclude with suggesting a stricter set of criteria for CSH that should be evaluated in future studies.

Carotid sinus hypersensitivity: disease state or clinical sign of ageing? Insights from a controlled study of autonomic function in symptomatic and asymptomatic subjects.

AIMS: This study sought to improve the currently limited understanding of the pathophysiology of carotid sinus hypersensitivity (CSH) by comparing autonomic function measured by heart rate variability (HRV) and baroreflex sensitivity inpatients with symptomatic CSH and asymptomatic individuals with and without CSH. METHODS AND RESULTS: Twenty-two patients with symptomatic CSH, 18 individuals with asymptomatic CSH, and 14 asymptomatic older individuals without CSH were recruited to our study. Non-invasive measurements of heart rate and blood pressure were obtained during 10 min of supine rest. Low frequency (LF), high frequency (HF), and total power spectral density (PSD) for HRV were determined using the autoregressive method. The baroreflex slope (BRS) and baroreflex effectiveness index (BEI) were determined using the sequence method for baroreflex sensitivity. There were significant increases in the LF-HRV (P = 0.014), total PSD (P = 0.031), LF:HF (P = 0.047), normalized (nu) LF-HRV (0.049), down ramp BEI (P = 0.017), and total BEI (P = 0.038) in the symptomatic CSH group compared with non-CSH controls. The asymptomatic CSH group had significantly higher LF-HRV (P = 0.001), total PSD (P = 0.002), nuLF-HRV (P = 0.026), and LF:HF (P = 0.030), as well as up, down, and total BRS (P = 0.012, P = 0.015, and P = 0.011, respectively) and BEI (P = 0.049, P = 0.001, and P = 0.006, respectively) than non-CSH control participants. CONCLUSION: This study has demonstrated an association between CSH with increased resting sympathetic activity and baroreflex sensitivity regardless of the presence of symptoms, indicating the presence of autonomic dysregulation in individuals with CSH. Our findings therefore suggest that CSH is part of a generalized autonomic disorder but do not differentiate between asymptomatic and symptomatic individuals.

Home orthostatic training in vasovagal syncope modifies autonomic tone: results of a randomized, placebo-controlled pilot study.

AIMS: To detect possible autonomic changes due to home orthostatic training (HOT) and to assess the feasibility of a larger, placebo-controlled study of HOT in vasovagal syncope (VVS). METHODS AND RESULTS: Twenty-two consecutive patients, aged 18-85, diagnosed with VVS following a positive head-up tilt-table test were randomized to 40 min of HOT (n = 12) or 10 min of sham training (n = 10) daily for 6 months. Baroreflex sensitivity (BRS) and heart rate variability (HRV) were measured at weeks 0, 1, 4, and 24. Symptom response was assessed by event diaries. Home orthostatic training resulted in increases in up and down slope BRS at week 4 (e(log difference) = 1.59, 95% CI = 0.84-3.03 and 1.79, 95% CI = 1.00-3.22) and week 24 (e(log difference) = 1.75, 95% CI = 1.01-3.06 and 1.53, 95% CI = 0.66-2.68) compared with placebo. Relative improvements in low- and high-frequency HRV were also observed in the HOT group compared with placebo at week 4 (e(log difference) = 3.22, 95% CI = 1.06-9.86 and 3.19, 95% CI = 1.03-10.59) and week 24 (e(log difference) = 2.11, 95% CI = 0.72-6.17 and 2.13, 95% CI = 0.52-8.79). Fifty percentage of HOT subjects and 20% of control subjects were syncope-free at 6 months. CONCLUSION: This was the first placebo-controlled study in orthostatic training which has demonstrated that such a study is indeed feasible. An enhancement in overall autonomic tone is observed with HOT in tandem with a non-significant trend in symptom improvement. A larger, adequately powered, randomized controlled trial of tilt-training is now needed.

Vasovagal syncope in the older person: differences in presentation between older and younger patients.

BACKGROUND: vasovagal syncope (VVS) has been diagnosed with increasing frequency in older people since the description of the head-up tilt table test (HUTT). There is, however, a paucity of research describing the clinical features of VVS in this group. To address this issue, we investigated the age distribution and differences in clinical characteristics associated with age in patients diagnosed with VVS by HUTT at our tertiary referral centre. METHODS: 1,060 consecutive patients with tilt-positive VVS were identified from a prospective database containing the demographic and clinical information of individuals assessed in our unit over a 10-year period. VVS was diagnosed with appropriate haemodynamic changes during HUTT and accompanying symptom reproduction. RESULTS: we found a bimodal age distribution with a small peak at 20-29 years and a larger peak at 70-79 years. Patients aged > or =60 years were less likely to report total loss of consciousness [odds ratio (OR) 0.50, 95% confidence interval (CI) = 0.38-0.64], near loss of consciousness (OR 0.53, 95% CI = 0.40-0.70) or palpitations (OR 0.45, 95% CI = 0.28-0.72) and more likely to present with unexplained falls (OR 2.33, 95% CI = 1.36-4.32). The typical provoking factors of prolonged standing (OR 0.55, 95% CI = 0.40-0.72), posture change (OR 0.61, 95% CI = 0.46-0.82) and hot environments (OR 0.57, 95% CI = 0.42-0.78) were also less common in older patients. CONCLUSION: in our large study population, VVS was more common in older patients. The clinical presentation differed significantly between the two groups. Older patients were less likely to give a typical history and therefore clinicians need to have a high index of suspicion when evaluating the older patient presenting with collapse or unexplained falls.

Should We Ever Pace for Carotid Sinus Syndrome?

Carotid sinus syndrome has been associated with transient loss of consciousness for millennia, and while steeped in cardiovascular lore, there is little in the way of solid evidence to guide its main treatment modality, permanent cardiac pacing. This article reviews the history of the condition in the context of its contemporary understanding before examining three key concepts in the consideration of what constitutes a manageable disease: first, is there a pathophysiologic rationale for the disease (in this case carotid sinus syndrome)? Second, is there a good diagnostic test that will identify it reliably? And finally, is there a convincingly evidence-based treatment for the disease? Relevant literature is reviewed, and recommendations made in how we view pacing in the context of this intriguingly opaque condition.

Machine learning as a diagnostic decision aid for patients with transient loss of consciousness.

BACKGROUND: Transient loss of consciousness (TLOC) is a common reason for presentation to primary/emergency care; over 90% are because of epilepsy, syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnoses are common, and there are currently no validated decision rules to aid diagnosis and management. We seek to explore the utility of machine-learning techniques to develop a short diagnostic instrument by extracting features with optimal discriminatory values from responses to detailed questionnaires about TLOC manifestations and comorbidities (86 questions to patients, 31 to TLOC witnesses). METHODS: Multi-center retrospective self- and witness-report questionnaire study in secondary care settings. Feature selection was performed by an iterative algorithm based on random forest analysis. Data were randomly divided in a 2:1 ratio into training and validation sets (163:86 for all data; 208:92 for analysis excluding witness reports). RESULTS: Three hundred patients with proven diagnoses (100 each: epilepsy, syncope and PNES) were recruited from epilepsy and syncope services. Two hundred forty-nine completed patient and witness questionnaires: 86 epilepsy (64 female), 84 PNES (61 female), and 79 syncope (59 female). Responses to 36 questions optimally predicted diagnoses. A classifier trained on these features classified 74/86 (86.0% [95% confidence interval 76.9%-92.6%]) of patients correctly in validation (100 [86.7%-100%] syncope, 85.7 [67.3%-96.0%] epilepsy, 75.0 [56.6%-88.5%] PNES). Excluding witness reports, 34 features provided optimal prediction (classifier accuracy of 72/92 [78.3 (68.4%-86.2%)] in validation, 83.8 [68.0%-93.8%] syncope, 81.5 [61.9%-93.7%] epilepsy, 67.9 [47.7%-84.1%] PNES). CONCLUSIONS: A tool based on patient symptoms/comorbidities and witness reports separates well between syncope and other common causes of TLOC. It can help to differentiate epilepsy and PNES. Validated decision rules may improve diagnostic processes and reduce misdiagnosis rates. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with TLOC, patient and witness questionnaires discriminate between syncope, epilepsy and PNES.

Results of carotid sinus massage in a tertiary referral unit--is carotid sinus syndrome still relevant?

BACKGROUND: carotid sinus hypersensitivity (CSH) is associated with syncope, drop attacks and unexplained falls in older people. However, a recent study has also reported a prevalence of 35% in asymptomatic community-dwelling older people. OBJECTIVE: we conducted a retrospective observational study to investigate the haemodynamic and symptom responses of a large cohort of patients undergoing carotid sinus massage (CSM). METHODS: the electronically stored haemodynamic data of 302 consecutive patients, aged 71 +/- 11 years, investigated with CSM for unexplained falls and syncope was analysed. Bilateral sequential CSM was performed in the supine and upright positions with continuous electrocardiogram (ECG) and non-invasive beat-to-beat blood pressure monitoring (Taskforce, CN Systems, Austria). CSH (CSH) was defined by maximal R-R interval > or =3 s (cardioinhibitory) and/or a systolic blood pressure drop of > or =50 mmHg (vasodepressor). RESULTS: a total of 74/302 (25%) subjects had CSH, 37 (50%) of which were cardioinhibitory (CI) and 37 (50%) were vasodepressor (VD) subtypes. Subjects with positive CSM were significantly older (75.2 vs 70.2 years, P < 0.001), and more likely to be male (32% vs 19%, P < 0.01). CSH was diagnosed with right-sided CSM alone in 45 (61%) subjects and erect CSM only in 36 (49%) subjects. Symptom reproduction was more likely with the CI than the VD subtypes (82% vs 28%; P < 0.001). CONCLUSION: CSH was diagnosed in 25% of patients investigated with CSM at our specialist unit, lower than the prevalence of 39% reported for community-dwelling older individuals. This discrepancy may be explained by selection bias and demographic differences, but raises the possibility of CSH being an age-related epiphenomenon rather than a causal mechanism for syncope, drop attacks and unexplained falls. Our observations have important implications for clinical practice and the development of future research strategies.