ASK THE GP: No explanation for two years of blackouts

ASK THE GP: My father-in-law, 70, has had fainting episodes for the past two years with no explanation

My father-in-law, 70, has had fainting episodes for the past two years. When he blacks out, it’s usually twice in two hours with little warning, and he is unconscious for 20 to 30 seconds. He broke his jaw in one of the falls — we are all concerned.

Sara Brindley, Sheffield.

I suspect he is suffering from syncope, fainting caused by a temporary reduction in the flow of blood and oxygen to the brain. It is usually triggered by a sudden drop in blood pressure and resolves itself once the blood flow resumes. However, this doesn’t mean it isn’t dangerous — as his broken jaw attests.

There are other causes of a sudden loss of consciousness, including seizures, intoxication, metabolic disturbances (e.g. low blood sugar) and conversion disorders (psychological conditions). But the fact your father-in-law is in generally good health, yet has suffered these sudden and worrying episodes for two years, leads me to conclude that these are not relevant in his case.

There are other causes of a sudden loss of consciousness, including seizures, intoxication, metabolic disturbances (e.g. low blood sugar) and conversion disorders (psychological conditions) [file photo]

So, the questions remain: what is the cause? And how can these episodes be prevented?

In terms of the cause, there are three main possibilities: neurological syncope, also known as reflex syncope, caused by a glitch in the autonomic nervous system; orthostatic syncope, when the blood pressure drops on standing or when standing in a hot, crowded place; and cardiovascular syncope, which is related to heart problems.

Made up of the brain, nerves and spinal cord, the nervous system regulates heart rate and blood pressure. In those with neurological syncope, something as simple as a laugh or a sneeze can stop the nervous system working properly, resulting in blood pressure falling and the person fainting.

This could be the cause, but I think it is not the most likely.

The low blood pressure of orthostatic syncope is often due to other health conditions, such as diabetes or medication for high blood pressure or depression. In your longer letter, you describe your father-in-law as active and in relatively good health, which makes me suspect this is unlikely to be the cause, either.

Write to Dr Scurr 

To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email [email protected] — including contact details. 

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Always consult your own GP with any health worries.

Taking into account his age, I think it is most likely a heart problem is intermittently interrupting the blood supply to his brain and causing him to faint. If this is the case, it is surprising that it has gone undetected until now. You write that your father-in-law had surgery for prostate cancer last year, and such a major operation would have been preceded by detailed tests, especially with his history of collapsing.

Cardiac syncope is usually caused by an abnormal heart rhythm, a common condition for which various treatments are available.

Investigations begin with a resting electrocardiogram (ECG), which records the rhythm of the heart while the patient is lying down. However, problems are more likely to be picked up by a continuous period of recording, so patients may also be given a small monitor to wear at home for up to a week (known as continuous ambulatory ECG monitoring) or even an implanted loop recorder (often called a Reveal device).

About the size of a lighter, this device is inserted under local anaesthetic into the chest wall just below the collarbone. It can stay in place for a year or two, so should record what is happening in your father-in-law’s heart when he faints. The results can be read simply by holding a scanner to the skin.

You are right to be concerned. I hope your father-in-law has been fully investigated by a cardiologist — if not, then that possibility must be discussed with his GP.

It is important that any heart rhythm problem is diagnosed and treated, not only to stop the fainting, but also for his overall health.

IN MY VIEW… You need your ‘own’ GP – not a stranger

My 93-year-old neighbour recently tripped and fell at home. She severely bruised her face, but simply picked herself up. As she did that, a volunteer delivering audio books arrived and, after a brief discussion, took her to the local GP.

Not so long ago, my neighbour would have seen her own GP — a doctor who would have known her well enough to realise she was her usual self, apart from the bruising. Instead, the GP took one look at her and sent her to A&E 20 miles away.

The doctor there began a long list of tests, finishing with a CT scan. It was dark by the time she was sent home — without the results of her scan because the department was, by then, closed. There has been no follow-up since — no phone call, no visit from GP or nurse.

Not so long ago, my neighbour would have seen her own GP — a doctor who would have known her well enough to realise she was her usual self, apart from the bruising [file photo]

This scenario is all too common and, to my mind, illustrates how something vital has been lost in general practice — the one-to-one relationship between a patient and their ‘own’ doctor, a staple of the NHS since it was founded in 1948. This lack of personal connection may account for a new phenomenon: the inability of GPs to cope with uncertainty. This leads to what is called defensive medicine, in which tests are done on a ‘just in case’ basis, rather than relying on judgment, experience and skill.

The defensive medical care my neighbour received didn’t only expose her to unnecessary radiation, cost the NHS more money and add to the considerable burdens on the A&E department, it also illustrated the lack of care and kindness present in modern general practice.

However, there is hope on the horizon. Many younger and healthier patients are taking advantage of internet consultations for minor illnesses, such as respiratory infections or abdominal upsets.

This, I hope fervently, will free up GPs’ time, allowing them to build relationships with their more vulnerable patients and provide them with the care and attention they so richly deserve.

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