Fainting and blackouts in older adults: causes, assessment and falls

The NHS describes fainting as passing out for a short time. Typical warning symptoms are dizziness, sweating, feeling hot or warm, feeling sick and changes to vision. Usually the person wakes within 30 seconds. Causes the NHS lists include standing up too quickly (which can be a sign of low blood pressure), not eating or drinking enough, being too hot, being very upset, angry or in severe pain, heart problems, and drugs or too much alcohol.

The BGS summary stresses that syncope can have devastating consequences, including fall-related injuries, accidents or even death, and that older people are more likely to need emergency care, surgery or hospital admission because of it.

According to the BGS, citing European and World Falls guidelines, syncope in older adults often presents as falls. This may be because the person has no memory of losing consciousness, or because a near-faint led to a fall, especially in those with several other fall risk factors. That makes it harder to recognise and to work up. In people with unexplained falls, or whose history contains red flags for syncope, special attention to faints and near-faints is warranted.

The BGS also warns that when syncope is mistaken for other causes of transient loss of consciousness such as epileptic seizures, or presents as falls, people are often sent to several specialists and may have excessive testing. Specialist services that give a comprehensive assessment can improve the diagnostic yield and reduce unnecessary testing, and increasingly geriatricians are involved in assessing syncope because of the overlap with falls. For families, it helps to describe exactly what happened before, during and after: what the person was doing, whether they stood up, any palpitations, and what a witness saw.

The BGS lists orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. Guy's and St Thomas' NHS Foundation Trust notes that postural hypotension can follow dehydration, heart conditions causing a slow heart rate or heart failure, hormone problems such as low thyroid levels or uncontrolled diabetes, and nervous system conditions such as Parkinson's disease. The BHF adds that some medicines for high blood pressure, heart disease or depression, and some over-the-counter and herbal products, can lower blood pressure, and that blood pressure can drop after eating.

Because older adults often take several medicines, a medicines review is usually part of the assessment of a faint. Never stop a heart or blood pressure tablet on your own; discuss any suspicion with the GP or pharmacist.

The NHS says to call 999 if someone is not breathing, cannot be woken up within 1 minute, has not fully recovered or has difficulty with speech or movement, has chest pain or a pounding, fluttering or irregular heartbeat, has seriously hurt themselves before or after fainting, is shaking or jerking, fainted while exercising, or fainted while lying down. It says not to drive yourself to A&E.

If you see someone faint, the NHS advises staying calm and checking if they respond by gently shaking their shoulders; if they do not respond, shout for help, tilt the head back and lift the chin, and listen for breathing for at least 10 seconds. If breathing normally, lay them on their back and raise their legs.

The NHS says to see a GP after any faint, as it is probably nothing serious but important to get checked. The GP may ask about circumstances and medicines, check pulse and blood pressure lying and standing, and arrange tests. Guy's and St Thomas' describes simple GP tests for postural hypotension (blood pressure lying and standing and blood tests for thyroid and sugar levels), and further tests that may include an electrocardiogram (ECG) and a tilt table test, in which you lie on a couch that tilts while blood pressure and heart rate are monitored.

The BGS highlights that rapid access blackout services for older people exist and comprehensive assessment is linked to shorter hospital stays. Local pathways differ, so ask your GP what blackout, falls or syncope services are available.

The NHS suggests that if you feel about to faint you lie down with legs raised, or sit with the head lowered between the knees, drink water, cross your legs while standing or rock up and down on your toes, and clench your fists. For postural hypotension, Guy's and St Thomas' and the NHS suggest standing up slowly, sitting down again if dizzy, drinking more fluids but less caffeine, and a medicines review. Syncope and postural hypotension raise falls risk, so home safety and falls prevention matter.

On driving, the NHS says you must tell the DVLA if you are fainting regularly, and must not drive if your GP has referred you to a specialist and you are waiting to be assessed.