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Available online at

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Specic care programme for the elders

A multidisciplinary care pathway for the evaluation of falls and

syncope in geriatric patients
J.F.H. Wold a, J.H. Ruiter b, J.H. Cornel b, R.L.C. Vogels c, R.W.M.M. Jansen a,*
a

Department of Geriatric Medicine, Medical Center Alkmaar, Wilhelminalaan 12, 1815 Alkmaar, JD, The Netherlands
Department of Cardiology, Medical Center Alkmaar, Wilhelminalaan 12, 1815 Alkmaar, JD, The Netherlands
c
Department of Neurology, Medical Center Alkmaar, Wilhelminalaan 12, 1815 Alkmaar, JD, The Netherlands
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 9 March 2015
Accepted 25 May 2015
Available online xxx

Introduction: A multidisciplinary care pathway based on current guidelines was developed to evaluate
unexplained non-accidental falls and/or syncope in geriatric patients aged 65 years or older.
Material and methods: We applied the lean six-sigma methodology. In the assessment phase, we dened
the historic level of care for syncope patients in a small sample of patients. In the improvement phase, we
developed a new clinical pathway with a close collaboration between geriatricians, cardiologists and
neurologists. This 2 day structured diagnostic program included a comprehensive geriatric assessment,
evaluation of nutritional status and disabilities, laboratory tests, and 12-lead electrocardiogram. In case
of fall problems, brain-MRI or CT scans were performed. Blood pressure measurements for orthostatic
and postprandial hypotension were performed. When indicated, patients were seen by a neurologist,
cardiologist, dietician or old age psychiatrist. During the sustain phase, we implemented our new
program and critically evaluated 262 patients.
Results: Of the 262 patients, aged 79.6  6.5 years, only 44 patients were referred for evaluation of syncope
while in 117 patients, a syncope was diagnosed. Sixty-one patients were diagnosed with both a syncope and
separate falls. Only 6 of the 117 elderly patients had syncope without falling.
Conclusions: With this novel multidisciplinary pathway for the combined evaluation of unexplained nonaccidental falls and syncope, we achieved a diagnosis in 89% with a large overlap between falls and
syncope. Therefore, cardiologists, neurologists and geriatricians should collaborate for the evaluation of
falls and syncope.
2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

Keywords:
Care pathway
Non-accidental falls
Syncope
Evaluation
Lean six-sigma methodology

1. Introduction
Non-accidental falls and syncope are major public health issues
among older adults, and especially among very elderly persons.
Approximately one-third of community-dwelling elderly subjects
aged 65 years and older fall at least once each year and 15% fall at
least twice a year [1,2]. According to the European Society of
Cardiology (ESC) guidelines, non-traumatic transient loss of
consciousness (T-LOC) is divided into syncope, epileptic seizures,
Abbreviations: T-LOC, Transient Loss of Consciousness; FSDC, Fall and Syncope Day
Clinic; ESC, European Society of Cardiology; CGA, Comprehensive Geriatric
Assessment; BP, Blood Pressure; CSM, Carotid Sinus Massage.
* Corresponding author. Department of Geriatric Medicine, Medical Center
Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands.
Tel.: +31725482370.
E-mail address: r.w.m.m.jansen@mca.nl (R.W.M.M. Jansen).

psychogenic and miscellaneous causes [3]. Syncope is dened as a

T-LOC due to transitory global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous and complete
recovery [3]. Syncope is a common problem in the elderly. Above
70 years of age, it rapidly increases with an incidence rate of
approximately 50% in people aged 80 years according to the
Framingham studies [4]. A Danish nationwide study found that
the incidence rates of syncope were found higher than reported
before, rising from 40.2 per 1000-years at 70 years to 81.2 in the
age group above 80 years [5]. Due to the nature of syncope, there
will be a loss of muscle tone and subsequently the clinical
manifestation is often a fall. In the evaluation of falls in the elderly,
syncope as a cause of a fall should always be considered. It has
been recognized that patients with syncope often presents with
unexplained falls [6]. There is a signicant overlap between nonaccidental falls and syncope in elderly subjects and they are often
indistinguishable [6,7].

http://dx.doi.org/10.1016/j.eurger.2015.05.007
1878-7649/ 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007

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The causes of syncope are diverse and in the elderly there might
be multiple causes as explanation [8,9]. Multiple causes are
independent predictors of increased mortality [9]. In only half of
the patients, a witnessed account for a syncope event is available
[3]. Thirty to fty percent of patients with witnessed syncope have
amnesia for the loss of consciousness [10]. The prognosis of
syncope can be dened in terms of risk of syncopal recurrences,
falls, with negative consequences on anxiety and insecurity and
leading to a negative impact of the quality of life [7]. Previous
studies have shown that patients with a cardiac cause for the
syncope have higher mortality than patients with non-cardiac
syncope [11]. Poor outcomes are associated with the severity of the
underlying disease rather than with syncope per se [12]. Therefore,
it is of great importance to determine the cause of syncope.
The costs of falls and fall-related injuries are substantial. In the
Netherlands, the mean costs per fall were 9370 euro, and increased
with age to almost 15.000 euro at ages of 85 years or older [13].
Management of falls and syncope in an elderly geriatric
population is challenging. In up to 60% of cases, a witness account
is not available [3]. Even if state-of-the-art diagnostic procedures
are followed in specialized clinics, about 35% of the patients are left
without a good explanation for their syncope [14,15]. Geriatric
patients with falls and/or syncope are generally being evaluated
within different specialties, including cardiology, neurology,
internal medicine, geriatric medicine, surgery or emergency room
physicians. In the Dutch health care system, the patients who are
presented to health care professionals with a fall of syncope will
primarily be seen by the general practitioner. Patients presenting
for acute care are typically admitted to a hospital and observed for
some time. Diagnostic tests are performed depending on which
etiology is suspected. Elderly patients with frequent unexplained
fall and/or syncope will visit the hospital multiple times, visiting
different specialists and being subjected to different diagnostic
tests. Sometimes a diagnostic test will be performed multiple times.
As a result of these confusing diagnostic procedures, the time to
establish a diagnosis will increase, and it may be questioned
whether all patients have undergone the appropriate tests.
To evaluate both unexplained non-accidental falls and/or
syncope, we developed a novel multidisciplinary pathway for the
evaluation in geriatric patients aged 65 years or older based on the
current ESC guidelines on syncope and the guidelines on the
evaluation of falls [3,16,17]. In this study, we describe the
development of a multidisciplinary work-up with a close collaboration of geriatricians, cardiologists and neurologists at the medical
center in Alkmaar according to the lean sigma principles [14].

success parameters. The most important reasons to decide to

develop a clinical pathway were to improve the care of frail elderly
patients with unexplained falls or syncope, to optimize the
diagnostic pathway, to reduce the time period for the diagnostic
pathway and to prevent needless investigations. Based on the
current literature of elderly patients with syncope, we hypothesized that elderly patients with syncope would be presented as
patients with a fall [3]. Therefore, we decided that we had to
combine the fall and syncope evaluation in these geriatric patients
within one diagnostic care pathway. To optimize and standardize
the diagnostic evaluations we followed the ESC guidelines for the
diagnosis and management of syncope and the current guidelines
for fall evaluation [3,16,17].
Arbitrarily, we only included patients aged 65 years or older
with unexplained falls or T-LOC. We dened our success
parameters as followed: to see all patients within 4 weeks
following referral, to limit the diagnostic time period to a
maximum of 2 weeks, to perform all necessary investigations
according to the guidelines, including the cardiology and
neurology investigations within this time period, and to report
the general physician within one week after nishing the program.
During the assessment phase, we evaluated the medical charts
of 71 recent patients who were evaluated for syncope at the
departments of cardiology or geriatric medicine. During the
improvement phase, we developed a new optimal clinical pathway
plan including best practices, standardized decision trees and we
developed an ICT program for the diagnostic pathway to
standardize the pathway with a logistic planner.
Finally, during the sustain phase, we performed a critical
evaluation of a pilot phase and rened the diagnostic pathway. The
patient experience was captured during this period and we also
monitored compliance with guidelines and the referral criteria of
the patients. After the pilot phase, patient outcomes were
monitored and evaluated for the diagnostic yield, which we
dened as a cause of the fall or T-LOC or the conclusions leading to
a treatment.
All data were entered into a SPSS statistical le and analyzed by
descriptive statistics including frequencies, means and standard
deviations and percentages to determine subject characteristics.
To evaluate the normal distribution of continuous data, we used
the Kolmogorov-Smirnov tests. Continuous variables with a
normal distribution were analysed with the t-tests, otherwise
the Pearson Chi-squared test was used. Data are presented as
means  SD. P-values are considered signicant if < 0.05. We used
the SSPS version 20 software (SPSS Inc., Chicago, IL, USA).

2. Material and methods

3. Results
The multidisciplinary pathway was developed by a working
group, consisting of a geriatrician, cardiologist, neurologist, nurse
practitioner, a physiotherapist and a general manager of the
department of geriatric medicine. The nurse practitioner was the
pathway coordinator and took care of the medical care of the rst
patients in the initial phase of the program. During the
development period, an expert in the lean six-sigma methodology
afliated with Medtronic Hospital Solutions, Heerlen, the
Netherlands (Stijn J. Schretlen, MD) joined the working group.
The principles of this methodology have been published recently
[14]. Subsequently, several focus meetings were arranged for all
multidisciplinary caretakers who may become involved with the
care for these geriatric patients with non-accidental falls and/or
syncope. The lean six-sigma methodology is a highly structured
method to optimize the level of care, and in brief consists of three
essential phases: assess, improve and sustain phase. The approach
of the working group was divided into these three essential steps.
At the rst meeting of the working group, we dened the goals and

The assessment phase was carried out form January till the end
of June in 2011. In November 2011, we started with a pilot phase
till the end of December and in the beginning of 2012, we rened
the clinical pathway. We continued this program and included a
total of 262 patients, aged 65 years or more in May 2014. In this
paper, we report the results of the different phases of the care
pathway improvement project and report the overall results of the
included patients.
We did not request specic patient consent and ethical board
approval because the study was based on the standard evaluation of
geriatric patients with falls and/or syncope, without any implication in therapeutic decisions or use of sensitive patient data.
3.1. Assessment phase
We started to dene the historic level of care for syncope
patients at the departments of cardiology and geriatric medicine.

Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007

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Table 1
Baseline characteristics of patients being presented to the cardiology and geriatric
department of the historic situation prior to the Fall and Syncope Structured
Pathway.

Men
Women
1st contact
emergency
department
Mean age
Trauma
Yes
No
Unknown
Cardiac history
Yes
No
Unknown
Day care clinic
Admitted > 1 day
Out-patient clinic

Cardiology
department
(n = 45)

Geriatric
department
(n = 26)

28 (62%)
17 (38%)
20 (44%)

9 (35%)
17 (65%)
4 (15%)

68  17 years

82  7 years

8 (18%)
35 (78%)
1 (2%)

9 (35%)
17 (65%)
0

23 (51%)
20 (44%)
2 (4%)
11 (24%)
13 (29%)
21 (47%)

16 (62%)
10 (38%)
0
16 (62%)
3 (12%)
7 (27%)

In a small sample, we evaluated 45 patients visiting the

department of cardiology and 26 elderly patients who visited
the department of geriatric Medicine. In Table 1, we present the
baseline characteristics of both patient groups. The 45 patients
visiting the cardiology department were mainly men, relatively
young of age (mean age 68  17 years) and had in approximately
half of the cases a cardiac history. Approximately half were admitted
to the hospital and the rest were seen at the outpatient clinic. The
26 elderly patients seen at the department of geriatric medicine were
mostly women, with a mean age of 82  7 years, and had a history of
cardiac disease. They were primarily seen in the outpatient day clinic.
In Table 2, we present the data of the diagnostic evaluation and
diagnosis for both groups.
Most of the cardiology patients had a syncope (91%). The most
common diagnosis was reex syncope in these patients, which
were found in 49%. Of the cardiology patients, 22% had a syncope
described as a cardiac syncope. Orthostatic hypotension was found

Table 2
Diagnostic tests during evaluation and diagnosis at the end of evaluation.
Cardiology
department
(n = 45)

Geriatric
department
(n = 26)

Diagnostic test
Blood pressure
ECG
24 h ECG
Echocardiogram
CT/MRI brain
Exercise ECG (tolerance test)
24 h blood pressure
Rhythm observation
Head-up tilt test
MIBI/CAG

45 (100%)
45 (100%)
25 (56%)
38 (84%)
1 (2%)
24 (53%)
1 (2%)
19 (42%)
6 (13%)
3 (7%)

26 (100%)
25 (96%)
5 (19%)
4 (15%)
3 (12%)
2 (8%)
1 (4%)
1 (4%)
1 (4%)
0

Diagnosis
Syncope
No syncope
Unknown if fall or syncope
Reex syncope
Cardiac syncope
Orthostatic hypotension
Fall
Other
Unknown
Further diagnostic care

41 (91%)
4 (9%)
0
22 (49%)
10 (22%)
3 (7%)
Unknown
3 (7%)
8 (18%)
4 (9%)

13 (50%)
12 (46%)
1 (4%)
0
4 (15%)
9 (35%)
12 (46%)
5 (19%)
1 (4%)
10 (38%)

in 7% of the patients. Two patients were referred to a neurologist

for further evaluation.
Of the 26 elderly patients seen at the department of geriatric
medicine, half had experienced a syncope; in only 4 patients, a
cardiac syncope was suspected. The most common diagnosis was
orthostatic hypotension (35%).
At the department of geriatric medicine, most patients were
seen in a day care clinic without further follow-up. There were
multiple diagnostic tests performed. Blood pressure (BP) measurement and ECG were performed in nearly 100% of the patients.
Further testing was different between the cardiology and geriatric
patients. Patients visiting the department of cardiology underwent
frequent longer rhythm registration with a 24 h Holter ECG or
telemetry at admittance. Eighty-four percent of the cardiology
patients had an echocardiogram, 53% an exercise ECG, and in 9% an
implantable loop recorder was implanted. In the geriatric patients,
additional cardiac evaluation was performed in less than 20% of
these patients.
Patients were generally seen in a reasonable time, mean time to
rst visit from referral was 12 days at the department of
cardiology, but at the department of geriatric medicine, we found
the mean time to be 30 days. Thirty-six percent of the patients had
to wait for more than a month.
3.2. Improvement phase
During the next step, we developed a diagnostic program for a
new Fall and Syncope Day clinic (FSDC) based on the essential
elements of the evaluation of unexplained falls and/or syncope.
This structured program consisted of two separate days in the
day clinic of the department of geriatric medicine for elderly
patients aged 65 years or older. In Fig. 1, we present the two-day
program.
During the rst day, we included a Comprehensive Geriatric
Assessment (CGA), including a full clinical history, thoroughly
medication review, physical examination, cognitive examination,
nutritional status, and disabilities. This assessment was performed
by a geriatrician and nurse practitioner. An enhanced Fall And
Syncope Questionnaire was especially developed for the FSDC
based on the guidelines. The nurse practitioner performed tests
concerning disabilities (including visual acuity), malnutrition
(screening and questionnaire), screening of cognition and mental
state and anamnesis with partner or caregiver. All patients were
also evaluated by a physiotherapist for walking, walking aids,
balance, possible function disabilities and fall hazard. Following
the CGA, laboratory tests, 12-lead electrocardiogram and 24-hour
Holter ECG recordings were done. In case of fall problems, a brainMRI or CT scan was performed. At the end of this rst day, all
medical information was critically reviewed.
The second day was scheduled one week later in order to
arrange the specic appointments for the neurologist, cardiologist,
dietician and/or old age psychiatrist. In case the patient presented
with fall problems, the neurologist was consulted. Neurological
examination consisted of a neurological physical examination and,
if indicated, additional neurophysiological (EEG or EMG) investigations. In case we suspected a syncope or when a syncope could
not be ruled out, the patients was seen by a cardiologist. In case of a
suspected cardiac cause for a syncope, an echocardiogram, 24-hour
Holter recording, and when indicated, tilt testing with carotid
sinus massage (CSM) were performed. When an anxiety disorder or
psychiatric condition was diagnosed as a cause for (pseudo)
syncope, those patients were seen by an old age psychiatrist. When
a nutritional problem was suspected on the rst day, patients were
evaluated by a dietician.
During the second day, the patients arrived at the FSDC in the
morning after an overnight fast from midnight the previous day for

Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007

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Fig. 1. Schema of the structured Fall and Syncope Day Clinic (FSDC) care pathway. *: Echocardiography; **: Carotid Sinus Massage.

orthostatic and postprandial BP measurements. Patients started

with an active 10 minutes standing test for orthostatic BP
measurements, followed by meal test for postprandial BP
measurements. The BP tests took place in a quiet room at a
pleasant room temperature of 2124 8C. All patients voided before
the start of the BP measurements, and were familiarized with the
study protocol. BP was measured at the right upper arm using a
Welch Allyn vital signs monitor 300 device. After instrumentation,
the patients assumed the supine position for at least 10 minutes,
after which they stood up within 10 seconds and remained
standing for 10 minutes. Every minute following standing BP
measurements were taken. The patients were asked about possible
orthostatic symptoms.
Following a short break of 10 minutes, baseline BP was
measured twice in the sitting position. Subsequently, patients
ingested a standardized 292-kcal liquid meal served at room
temperature (consisting of 100 mL of Nutrical [Nutricia, Zoetermeer, The Netherlands] and 100 mL lactose-free whole milk, and
containing 65 g carbohydrate, 2 g fat, and 4 g protein) within
10 minutes in the sitting position. They resumed the sitting position
for 75 minutes after the start of the meal and BP measurements
were taken every 15 minutes. Every 15 minutes, the patients were
asked about possible postprandial symptoms [18].
After a lunch and a resting break of 30 minutes, patients were
evaluated by a neurologist, cardiologist, old-age psychiatrist and/
or dietician. At the end of day 2, all information were collected and
discussed in the multidisciplinary team. Based on all available
information, the diagnosis and advice for treatment were
discussed until we reached consensus. After this multidisciplinary
meeting, the diagnosis and treatment advice were discussed with
the patient and caregiver by the geriatrician and nurse practitioner.
The conclusions were given to the patient in a written report.
Subsequently, the general practitioner was informed by a written
report, including the ndings of all consultants.

3.3. Sustain phase

During the sustain phase, we started with the implementation
of our new program during a pilot period of two months. We
provided extensive support with embedding our new program and
critically evaluated the program based on the rst 15 patients for
the ne-tuning. In summary, we encountered three major
problems. The rst problem was the waiting time at the
department of radiology in case we requested a MRI/CT scan or
other X-rays in the evaluation of falls. We changed the program
and received a xed time slot for the MRI or CT scanning in the
afternoon for all patients. In case we did not have an indication for
imaging, we could cancel the time slot before noon. Secondly, we
limited the possibilities for other X-ray imaging, i.e. in case of
osteoarthritis, to prevent disruption and delay of the program.
The second problem was the 24 hour Holter evaluation on day
2 in case of the cardiology work-up. It took several days before the
results of the 24 hour Holter recordings were available. Therefore,
we moved the Holter recording to day one so that the results were
available for the cardiologist at day 2, one week later. In case we
had no indication for a cardiology work-up, we could skip the start
of the Holter registration at day 1.
The third major change to the program was that some of the
patients were quite exhausted at the end of the day. We
implemented more resting time between the evaluations, and
following lunch, patients were allowed to do a short nap of
30 minutes in a special relaxing chair.
3.4. Overall Patient outcome
A total of 270 elderly patients were referred by the general
practitioner or medical specialist with unexplained non-accidental
falls and/or unexplained T-LOC. We excluded 8 patients who did
not full the inclusion criteria. All of these 8 patients were under

Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007

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Fig. 2. Flow chart of all patients evaluated in the fall and syncope program with the diagnosis.

the age of 65 years. We included all 262 consecutive patients, aged

65 years or older, who were referred to the FSDC with unexplained
falls or T-LOC including the rst 15 patients of the pilot phase. Of
these 262 patients, 229 patients were seen by the cardiologist and
Table 3
Patient characteristics and co-morbidity in 262 patients.
Patient characteristics and
co-morbidity (262 patients)

(mean  SD)

Age mean (years)

Age range (years)
Gender: men/female
Body mass index (kg/m2)
Mini-Mental State Examination score
No. of medication (range)
No. of comorbidity (range)
Hypertension, n (%)
Hypercholesterolemia, n (%)
Diabetes Mellitus II, n (%)
Cerebral vascular accident, n (%)
Ischemic heart disorders, n (%)
Congestive heart failure, n (%)
Structural heart disease, n (%)
Rhythm disorders, n (%)
Atrial brillation, n (%)
Peripheral vascular disease, n (%)
Parkinson(ism), n (%)
Seizures, n (%)
Fractures, n (%)
Osteoporosis, n (%)
Cognitive impairment, n (%)
Psychiatric disorders, n (%)
Activities of daily living, n (%)
Independent/dependent
Instrumental activities of daily living, n (%)
Independent/dependent
Walking device, n (%)
Living, n (%)
Alone
With partner
Institutionalized

79.6  6.5
6595
82 (31%)/180 (69%)
26.0  4.1
27  3
7  4 (023)
9  4 (224)
175 (67%)
64 (24%)
50 (19%)
67 (26%)
62 (24%)
31 (12%)
51 (19%)
77 (29%)
61 (23%)
46 (18%)
14 (5%)
9 (3%)
117 (45%)
39 (15%)
36 (14%)
57 (22%)
198 (76%)/64 (24%)
162 (62%)/100 (38%)
137 (52%)
130 (50%)
112 (43%)
20 (7%)

evaluated for syncope. Fig. 2 and Tables 3 and 4 show the

characteristics of the total study population of the FSDC and the
referral reasons. It is noteworthy that our population was relatively
old with a mean age of almost 80 years. Two thirds of the patients
were female and with a very high number of co-morbidities as
could be expected in geriatric patients. All patients were using a
mean of 7  4 different medications.
Of the total group of 262 patients, all patients were evaluated
by the geriatrician and nurse-practitioner and 96% were evaluated
by a physiotherapist. Of the 262 patients, 229 patients (87%) were
evaluated by the cardiologist and 107 patients (41%) were
evaluated by the neurologist at the second day of the program.
The old age psychiatrist investigated 25 patients and 26 patients
were seen by the dietician. Although the ear-nose-throat
physician was not part of the program, 9 patients were sent to
him for formal evaluation of the vestibular system due to
dizziness complaints. The new diagnosis following the evaluation
are listed in Table 5.

Table 4
Referral reason and referring physicians in 262 patients.
Referral reasons and referring physicians (262 patients)
Referral by
Primary care practitioner
Cardiologist
Neurologist
Surgeon
Geriatrician
Rheumatologist
Others
Missing
Referral reasons
Fall
Syncope
Tendency to fall/dizziness
Missing

n (%)
116
15
32
26
37
4
14
18

(44%)
(6%)
(12%)
(10%)
(14%)
(2%)
(5%)
(7%)

155
44
48
15

(59%)
(17%)
(18%)
(6%)

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Table 5
Summary of nal diagnoses following evaluation in 262 patients.
Summary of nal diagnoses following evaluation
Rhythm or conduction disorder
Aortic stenosis
Cardiomyopathy
Reex syncope
Sinus carotid hypersensitivity
Neurologic disorders
Gait disorder
Parkinsonism
Polyneuropathy
Spine stenosis
Cerebrovascular accident
Seizure disorders
Progressive supranuclear palsy
Multiple system atrophy
Cervical myelopathy
Meningioma
Depression
Anxiety disorders
Cognitive impairment
Dementia
Orthostatic hypotension
Postprandial hypotension

n
34
10
5
18
3
16
26
26
10
7
4
2
1
1
1
13
42
81
7
140
130

Of the total of 262 patients, referred for the evaluation of falls

and syncope, only a very small number of patients (8 patients) did
not have a fall or syncope demonstrating that the referral criteria
for selecting patients worked very well. Of the 262 patients,
117 patients were diagnosed with a syncope of whom 50 patients
were presented by a fall. Sixty-one patients were diagnosed with
both a syncope and separate falls. Only 6 of the 117 elderly patients
had a syncope without falling. Of note is that only 44 of the
262 patients (18%) were referred for evaluation of syncope while in
117 patients a syncope was diagnosed (Table 4).
Less than half of the patients were referred by the general
practitioner to the FSDC, 6% of the patient by the cardiologist and
12% by the neurologist. From the surgery and orthopedics
disciplines 10% of the patients were referred to the FSDC mostly
after a fall outside the hospital. In addition, 14% of the surgery
patients were seen by the consultation service of the geriatrician
on the surgical wards. Following discharge of the patients an
appointment was made at the FSDC for the fall or syncope
evaluation.
Following geriatric evaluation, we found in one third of the
patients cognitive disorders. Most of the patients were evaluated
for the cognitive disorders after the fall and syncope work-up.
Orthostatic hypotension was found in 53% of the patients and
half of the patients had postprandial hypotension.
Of the 262 patients, 38% were dependent for the instrumental
ADL activities such as shopping, nancial aspects, transportation or
their administration (Table 3). Twenty-four percent of the patients
were dependent for the ADL activities, such as bathing or get
dressed. More than 50% of all patients were using walking devices.

4. Discussion
In this paper, we describe the development of a novel
multidisciplinary clinical pathway for the combined evaluation
of unexplained falls and T-LOC in elderly patients. Faced with the
complex problems of falls and syncope in the elderly patients with
extensive comorbidity and recognizing that patients with syncope
often presents with unexplained falls, we hypothesized that we
have to combine the evaluation of falls and T-LOC within one
multidisciplinary clinical pathway. In addition, cognitive decline
complicates many aspects of investigation and management of

falls and syncope. Taking advantage of the methods described in

the lean six-sigma principles, we had the opportunity to approach
these important clinical problems with a close collaboration
between geriatricians, neurologists and cardiologists to manage
the unexplained falls and syncope in this group of very old patients.
The clinical pathway has led to a more coherent, efcient and
complete diagnostic procedure for the patients we daily see in our
practice. The results presented from this study demonstrate that
the evaluation of unexplained falls and syncope in elderly patients
can be improved according to the ESC guidelines and the falls
guidelines by applying the lean sigma methodology.
Our clinical pathway for the evaluation of syncope is unique in
having a large geriatric population with a mean age of almost
80 years. The mean age of our patients is signicantly older than
previously described cohorts with a mean or median age of
65 years [4,5].
By applying the relevant guidelines, the number of tests
increased in our hospital but reduced the time to diagnosis
signicantly; we prevented all unnecessary investigations and
increased the diagnostic yield. Based on the small retrospective
evaluation of the diagnostic level of care in 2011, we concluded
that a high number of tests were performed in an unstructured and
incomplete way. In our small sample, there was no good sense of
the diagnostic decision-making, which was reected in the
diversity of diagnostic procedures chosen for patients presenting
with fall and syncope. This would suggest that the decision-making
was individualized and perhaps partly dependent of the knowledge of the physician. Interestingly, the number of diagnostics
cardiology tests in our relatively small group of patients from the
department of cardiology was quite similar in comparison with the
Picture registry [19]. However, orthostatic BP measurements were
not performed in our group, which is not in line with the ESC
syncope guidelines [3], while brain imaging was performed in the
Picture registry in almost 50% of their patients.
The development of a new multidisciplinary clinical pathway
depends on different factors. Among these factors, a shared view of
different specialties that the care has to be optimized and that this
needs to be done in cooperation with the different disciplines
involved is of utmost importance to collaborate within one
program. All participated physicians need to be committed to the
project to become successful. We focused on elderly patients
presented to the departments of cardiology, neurology and
geriatric medicine at our large non-academic teaching hospital.
The 262 patients included in our new FSDC program had a high
number of syncopal events. In 45% of the patients, syncope was
diagnosed and 5% of the patients had a pre-syncope. A high number
of patients with syncope presented with a fall, and in almost half of
the patients with syncope, the case was complicated with falls as
well. Most of the patients presented with falls were quite vague
about the symptoms of syncope or had amnesia for the syncope as
has been reported before [4,10]. This illustrates the complexity in
history taking in elderly patients presenting with falls and syncope.
These numbers are strikingly different than the numbers found in
our baseline measurement during the assessment phase, in both
the cardiac and geriatric evaluation. Therefore, as we hypothesized, most of the elderly patients have huge overlap between falls
and syncope and should be evaluated according an integrated
approach.
The overlap between falls and syncope has been described
before [7,8]. The group of Kenny reported 20 years ago on the
outcome of an integrated approach to the investigation of
dizziness, falls and syncope in elderly patients and found a high
diagnostic yield [20]. These authors found an overlap in falls and
syncope in a quarter of patients while we found that 43% of the
patients with syncope presented with a fall. In addition, most of
our patients with syncope had falls as well, which complicated

Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007

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history taking. One third of our patients had cognitive impairment,

including dementia, which was an additional complicating factor
in history taking.
Less than half of the patients were referred by the primary care
practitioner, which was a much lower number than we expected
before the start of this new program. Among our goals of the FSDC,
an important reason was to be an out-of-hospital service to the
general practitioners. The general outline of the pathway was
discussed with the primary care physicians and for them it was
important that clear indications for referral of the appropriate
patients were available. One of the most efcient changes of our
program was the introduction of a combined multidisciplinary
evaluation with standardized referral criteria. Indeed, in patients
referred for fall evaluation, we found a high yield of syncope. Of the
262 patients included in this study, 59% of the patients were
referred due to a fall. Only 17% of the patients were referred for a
suspected syncope, while we diagnosed a syncope in 117 patients.
Of the syncope group, 61 patients were found to have a fall and
syncope as separate problems. This study underscores the clinical
problem for primary care practitioners that they can easily miss a
syncope presented by a fall in elderly patients. This supports our
prior hypothesis that elderly patients should be evaluated for a fall
and syncope, and not solely for a fall or syncope. In addition,
specic guidelines for the clinical presentation of older people with
atypical presentation of syncope are still needed.
We have dened clear inclusion criteria for the FSDC. Ten
patients were referred due to a tendency to fall or dizziness, and in
8 patients, no fall or syncope was diagnosed.
Of the 117 patients diagnosed with syncope, a surprisingly high
number (24%) had a cardiac cause for the syncope. As expected, the
patients in this study had a high number of co-morbidity and use of
medication. Due to the multidisciplinary and extensive diagnostic
pathway the number of new diagnosis was impressive. No clear
diagnosis was found in only 16 patients (6.1%) with syncope and in
12 patients (4.6%) with falls. Therefore, we found a diagnosis in
89.3% of this study group.
Fifty-three percent of the patients had orthostatic hypotension
and 50% had postprandial hypotension. These numbers are
comparable to the study of Vloet and co-workers and provide
further evidence that in elderly patients postprandial hypotension
is extremely common and clinical relevant [18]. These investigators reported that orthostatic- and postprandial hypotension occur
frequently but not necessarily together in geriatric patients. It has
been demonstrated before that postural blood pressure measurements had the highest yield with respect to affecting diagnosis and
management of syncope [21]. Jansen argued before that postprandial hypotension should be considered in elderly patients with
non-accidental falls and syncope [22]. The evaluation for
postprandial hypotension should be included in the workup for
syncope.
Neurologic cause of fall and syncope were diverse and relative
frequent. Four patients had epileptic seizures. Three patients were
diagnosed with a possible or probable multiple system atrophy or
progressive supranuclear palsy, which are uncommon diseases. A
fall can be the rst symptom of such disease. Psychiatric burden
was also high. We found in 42 patients (16%) symptoms of anxiety,
only 3 patients were known with an anxiety disorder prior to our
evaluation. This might be an overestimation since we included all
patients who were found to have signicant anxiety problems such
as fear of falling and/or syncope. Anxiety problems or fear of falling
could lead to inactivity, social isolation and further loss of strength
and ability to walk with an increased risk of falling. Depression was
found in 13 patients (5%) further contributing to this negative
trend. Therefore, we conclude that a FSDC should have easy access
to psychiatric evaluation. Also, one third of the patients had
cognitive disorders, which are a major risk factor of falling.

5. Conclusions
Applying a structured approach based on the lean six-sigma
principles, we were able to develop and implement a novel
multidisciplinary clinical pathway for the combined evaluation of
unexplained falls and/or syncope in elderly patients. The results of
this study demonstrate that there is a huge overlap between falls
and syncope in very elderly patients. Therefore, cardiologists,
neurologists and geriatricians should collaborate within one
structured program for the combined evaluation of unexplained
non-accidental falls and syncope. With this collaboration of
different specialties, we were able to achieve a diagnosis in 89%
of these geriatric patients.
Contribution of this paper
All authors helped conceive and design the layout and content
of this paper. Wold, Ruiter and Jansen contributed equally to
authorship, but all authors critically reviewed and approved the
nal version of the submitted manuscript.
Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.
Acknowledgement
The authors are grateful to Cindy Ooijevaar, nurse practitioner;
Erika Verblaauw and Gertie Reinders, management team of the
department of geriatric medicine; and Jolanda Smulders-Bosch,
department of innovative clinical care, Medical Center Alkmaar, for
their work with developing and implementing the new multidisciplinary clinical pathway. The help of Els Doejaaren, Msc with data
management and analysis is greatly appreciated. The authors
would like to acknowledge Stijn Schretlen, Medtronic Hospital
Solutions, Heerlen, The Netherlands for his help in applying the
lean six-sigma methodology.
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Please cite this article in press as: Wold JFH, et al. A multidisciplinary care pathway for the evaluation of falls and syncope in geriatric
patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.007