Geriatric Emergency Medicine Fellowship Journal Club: Syncope Risk Stratification & Geriatric-Specific Clinical Decision Rules

Volume 4 | Issue 1 | Article 2 - Journal Club

Kyle R. Burton, MD, MPP, Phillip D. Magidson, MD, MPH
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Emergency medicine physicians use a range of clinical decision aids to improve diagnostic
accuracy and limit unnecessary resource use.1 While some aids are pathology-specific and others are
population-specific, rarely do decision aids fit both categories. As we continue to discover the nuances of
care for older patients through geriatric emergency medicine, we should expect the development of
several tools to assist in this population’s care.

When applied appropriately, clinicians can use clinical decision aids to overcome biases and
make literature-supported conclusions about treatment and patient disposition. Unfortunately, unique
patient characteristics and complex/overlapping disease processes influence presenting symptoms and
diagnostic results, thus adversely affecting decision tool function.2 Additionally, the many decision aids
created/validated in studies that exclude older adults cannot be applied to this population in clinical
practice. Despite these challenges, a number of decision aids have been shown to improve clinical care.3
The best of these tools are simple to apply, use routinely collected information, inform a clinically
important decision, and safely reduce resource use compared with clinician gestalt.4 Clearly, clinical
decision tools are most effective for pathology with a wide range of management approaches that often
unnecessarily increase the cost of care delivery.5,6

Syncope, the transient loss of consciousness and postural tone, is a common presenting complaint
that results in the hospitalization of many patients who ultimately have a benign clinical course. The
population aged 65 and older experience disproportionately high hospitalization rates that increase by
the decade of life, with 58% of those over 80 years of age admitted to the hospital when they present
with the chief complaint of syncope.7 Approximately 33% to 56% of syncope patients are discharged after
a full hospital evaluation without a definitive diagnosis.7 When unable to identify the specific etiology, a
potential miss could be catastrophic. Even with infrequent diagnosis or therapy provided, syncope incurs
a mean cost of $5,400 per hospitalization.8 Up to 60% of admitted syncope patients are discharged
without receiving any therapeutic intervention for syncope.9

It is reasonable to think that a decision aid might improve resource use while identifying the
subset of patients with life-threatening causes for their syncope warranting admission. In this journal
club, we explore the additional benefit of a syncope risk stratification tool focused on delineating the
management of the highest-risk older patient population. The first authors of the two risk stratification
tools that were discussed both participated in this journal club.

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