“Those who suffer from frequent and strong faints, without any manifest cause die suddenly”
∼Hippocrates (460-373 BC)
A spell is a brief period where a person is dissociated from the world around them or loses consciousness. There are many possible causes of spells (Table 1) (1). The two major causes of spells are seizures and syncope. Often making the diagnosis is elusive (2). The approach to the differential diagnosis is given in Table 2.
The incidence of seizures increases exponentially after 60 years of age (3). In older persons it can take up to 17 years to make the diagnosis. Seizures may be either generalized (toniclonic, absence, myoclonic or atonic) or partial, where they are unilateral and consciousness can be preserved. Complex partial and generalized tonic clonic seizures make up over half of seizures (4). Fyodor Dostyeski (1821–1880) was the prototypic example of complex partial seizures where he presented with ecstasy or anguish followed by convulsions. Complex partial seizures can present with hallucinations (visual, auditory or olfactory), psychomotor (dysphagia, chewing, taking off clothes) or temporal (dreamy state, memory problems, fear or déjà vu). Diagnostic clues include elevated prolactin for a 20 to 60-minute window following the seizure and, in some cases, elevated CPK or lactate (5, 6). The diagnosis of seizures is made by electroencephalogram. Artificial intelligent techniques are being developed to enhance the diagnosis (7).
Cardiogenic syncope - heart fails as a pump
Orthostatic syncope - reduced venous return
Abnormal arterial vasodilation - inappropriate arterial vasodilation
Cardiac syncope can be due to tachycardia, bradycardia, asystole, prolonged QT, hypertrophic obstructive cardiac myopathy, amyloid cardiac infiltration, or Brugada syndrome. Brugada syndrome is right bundle branch block with ST segment elevation in V1 to V3 (9). It occurs predominantly in middle aged persons. Persons with this syndrome have a propensity to develop sustained ventricular arrythmias. Carotid sinus hypersensitivity occurs in 40% of adults over 65 years (10). It results in abnormal cerebral autoregulation. It is a common cause of falls in older individuals. Diagnosis is made by doing carotid sinus massage. If there is a pause of greater than 7 seconds in older persons, this is diagnostic. It should be avoided in persons with a carotid brunt, recent stroke or myocardial infarction or a history of ventricular tachycardia (11). The work up for cardiac syncope is outlined in Figure 1. Persons with autonomic neuropathy are at high risk of having lethal arrythmias (“death in the bed syndrome”) (11). If no obvious cardiac causes, orthostasis or postprandial hypotension are present, an elderly person with syncope should be considered for a subcutaneous implantable loop recorder (12). Ambulatory recorders rarely are useful as usually the next syncopal episode occurs months after the previous one.
Orthostatic syncope occurs when there is greater than 20% of the blood volume pooling in the extremities on standing.
It is often associated with excessive loss of water or blood, failed vasoconstriction (varicose veins), sarcopenia (lack of muscle contraction) increased chest or abdominal pressure (e.g., abdominal corset), drugs, neuropathy or vasodilation due to spending time in a jacuzzi (13). Orthostasis is not always associated with dizziness so standing blood pressure needs to be measured in all older persons and in all persons with diabetes mellitus. Table 5 lists the treatment approaches for orthostatic hypotension (14).
Postprandial Hypotension (“Big Mac Attack”)
Thirty to 120 minutes following a meal blood pressure can drop fairly dramatically. This postprandial hypotension is variable and occurs more often in the morning (15). It occurs in about a quarter of older persons and results in falls, syncope, stroke, myocardial infarction and death. The fall in blood pressure is mainly due to carbohydrates in meals. The fall in blood pressure is due to the vasodilatory of calcitonin gene related peptide (16). Postprandial hypotension can be treated with coffee in the morning only, small meals, fiber with the meals and alpha-1 glucosidase inhibitors, e.g., acarbose and miglitol, which slow gastric emptying by increasing glucagon-like peptide 1.
With vertigo “the external world seems to revolve around the individual or the individual seems to revolve in space.” Like syncope there are multiple causes of dizziness (19). These include benign paroxysmal positional vertigo (BPPV), Meniere’s disease, labyrinthitis, vestibular neuronitis, acoustic neuroma, arteriosclerosis, ototoxicity and osteoarthritis.
BPPV occurs in the fifth to seventh decades of life and is responsible for 20% of all cases (20). It is bilateral in 10%. It can be treated with the Epley maneuver.
Meniere’s disease occurs when endolymph cannot be drained from the inner ear (21). It presents with episodes of dizziness and tinnitus. There is fluctuation in sensorineural hearing and a feeling of pressure in the ear. Table 6 lists possible treatments for Meniere’s disease.
Superior semicircular canal dehiscence occurs in 0.4% to 1.5% (22). It presents with disequilibrium that can be triggered by noise, gaze or pressure and can be associated with nystagmus. Treatment consists of a pressure equalization tube or surgical repair (23).
Finally, a number of exercises have been developed to treat dizziness (24). These include Brandt-Baroff Habituation exercise, the Sermont (Liberatory) Maneuver, Gaze Stabilization exercises and Crawthorne-Cooksey exercises. These exercises are variably effective.
Spells are very common in older persons. They result in falls, frailty, disability and death. The diagnosis is often difficult to make. With the exception of postprandial hypotension, treatment success is variable.
Mechanic OJ, Grossman SA. Syncope and related paroxysmal spells. StatPearls Publishing LLC; 2019, Apr 3 PMID: 29083598 [Epub]
McKeon A, Vaughan C, Delanty N. Seizure versus syncope. Lancet Neurol 2006;5:171–180.
Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures I Rochester, Minnesota: 1935–1984.
Lezaic N, Roussy J, Masson H, et al. Epilepsy in the elderly: Unique challenges in an increasingly prevalent population. Epilepsy Behav 2019;102:106724. [Epub ahead of print].
Nass RD, Sassen R, Elger CE, Surges R. The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure 2017;47:51–65.
Javali M, Acharya P, Shah S, et al. Role of biomarkers in differentiating new-onset seizures from psychogenic nonepileptic seizures. J Neurosci Rural Pract 2017;8:581–584.
Daoud H, Bayoumi MA. Efficient epileptic seizure prediction based on deep learning. IEEE Trans Biomed Circuits Syst 2019;13:804–813.
Palaniswamy C, Aronow WS, Agrawal N, et al. Syncope: Approaches to diagnosis and management. Am J Ther 2016;23:e208–e217.
Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: A distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20:1391–1396.
Cronin H, Kenny RA. Cardiac causes of falls and their treatment. Clin Geriatr Med 2010;26:539–567.
Bissinger A. Cardiac autonomic neuropathy: Why should cardiologists care about that? J Diabetes Res 2017;2017:53741767. Doi: https://doi.org/10.1155/2017/5374176. [Epub 2017 ahead of print]
Bisignani A, De Bonis S, Mancuso L, et al. Implantable loop recorder in clinical practice. J Arrhythm 2018;35:25–32.
Freeman R, Abuzinadah AR, Gibbons C, et al. Orthostatic hypotension: JACC state-of-the-art review. J Am Coll Cardiol 2018;72:1294–1309.
Joseph A, Wanono R, FLamant M, Vidal-Petiot E. Orthostatic hypotension: A review. Nephrol Ther 2017;13(Suppl 1):S55–S67. Doi: https://doi.org/10.1016/j.nephro.2017.01.003.
Morley JE. Editorial: Postprandial hypotension—the ultimate Big Mac Attach. J Gerontol A Biol Sci Med Sci 2001;56:M741–M743.
Edwards BJ, Perry HM 3rd, Kaiser FE, et al. Relationship of age and calcitonin gene-related peptide to postprandial hypotension. Mech Ageing Dev 1996;87:61–73.
Trahair LG, Horowitz M, Jones KL. Postprandial hypotension: A systematic review. J Am Med Dir Assoc 2014;15:394–409.
Shams A, Morley JE. Editorial: Autonomic neuropathy and cardiovascular disease in aging. J Nutr Health Aging 2018;22:1028–1033.
Zwergal A, Dieterich M. Vertigo and dizziness in the emergency room. Curr Opin Neurol 2019;Nov 16, doi: https://doi.org/10.1097/WCO.0000000000000769. [Epub ahead of print]
Balatsouras DG, Koukoutsis G, Fassolis A, et al. Benign paroxysmal positional vertigo in the elderly: Current insights. Clin Interv Aging 2018;13:2251–2266.
Harcourt J, Barraclough K, Bronstein AM. Meniere’s disease. MBJ 2014;349:g6544. Doi: https://doi.org/10.1136/bmj.g6544.
Mau C, Kamal N, Badeti S, et al. Superior semicircular canal dehiscence: Diagnosis and management. J Clin Neurosci 2018;48:58–65.
Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, et al. Outcomes and complications in superior semicircular canal dehiscence surgery: A systematic review. Laryngoscope 2016;126:1218–1224.
Kendall JC, Hartvigsen J, Azari MF, French SD. Effects of nonpharmacological interventions for dizziness in older people: Systematic review. Phys Ther 2016;96:641–649.
Disclosures: The authors declare there are no conflicts.