Have you ever been told that your heart rate is slow, or maybe too slow?
This is called bradycardia, and it’s fairly common in older adults. Whereas in younger adults, a slow heart rate is often due to being in good cardiovascular shape, with aging, a slower heart rate often reflects changes in the heart’s electrical system. (Medications are another common cause.)
This can be an issue because a slower heart rate can cause symptoms such as fatigue, dizziness, falls, or trouble keeping up with usual activities.
Fortunately, in certain situations, a pacemaker can be an effective treatment that helps older adults feel substantially better.
To help older adults learn more about bradycardia and when to consider a pacemaker, I interviewed cardiologist Cara Pellegrini, MD, who specializes in cardiac electrophysiology. Here’s what’s most important to know, based on our conversation.
What Is a Pacemaker and How Does It Help a Slow Heart Rate?
A pacemaker is a small electronic device that monitors the heart’s electrical activity and can stimulate the heart to produce a heartbeat when needed.
Pacemakers are generally used when the heart is beating too slowly.
A pacemaker has three basic components:
- A battery, which powers the device
- A computer, which monitors the heart and determines when pacing is needed
- A connection to the heart, either through traditional wires called leads or through electrodes built into a leadless pacemaker
The pacemaker continually monitors what the heart is doing.
If enough time passes without an appropriate heartbeat, the device delivers a small electrical stimulus that causes the heart to beat.
People generally do not feel the electrical stimulation from an ordinary pacemaker.
For many older adults with symptomatic bradycardia, a pacemaker is used primarily to improve symptoms and quality of life. With certain types of heart block, however, a pacemaker can also be life-saving.
To understand when a pacemaker is needed, it helps to first understand what doctors mean by a slow heart rate.
What Is Bradycardia, or a Slow Heart Rate?
Bradycardia is the medical term for a slow heart rate.
It is usually defined as a heart rate below 60 beats per minute.
But a heart rate below 60 does not automatically mean something is wrong.
For example, younger athletic adults commonly have resting heart rates in the 40s or 50s without having a medical problem. Some older adults may also have a relatively slow resting heart rate and feel perfectly well.
So the heart-rate number by itself does not determine whether treatment is needed.
What matters more is whether the heart is beating fast enough for the body’s needs, and whether the heart is able to increase the heart rate enough with physical activity.
How the heart’s electrical system works
The heart is a pump, but it also has its own electrical system.
Normally, each heartbeat begins in the sinus node, also called the sinoatrial or SA node. You can think of the sinus node as the heart’s natural pacemaker.
The sinus node generates an electrical signal. That signal travels through the upper chambers of the heart, called the atria, and then reaches the atrioventricular, or AV, node.
From there, the signal travels into the heart’s lower pumping chambers, the ventricles.
This allows the different parts of the heart to contract in a coordinated way.
Problems with either generating this electrical signal or transmitting it through the heart can cause the heart rate to become too slow.
What Heart Rate Is Too Low for an Older Adult?
There is no single heart-rate number that is too low for every older adult.
A very low heart rate, such as one in the 20s or 30s, is clearly concerning.
In an older person, a resting heart rate in the 40s may also warrant further evaluation, especially if the person is having symptoms such as dizziness, fatigue, fainting, or difficulty with exertion.
But doctors also need to consider what happens to the heart rate during physical activity.
Some people have a resting heart rate in the 50s or 60s and feel fine while sitting. But when they walk, climb stairs, or otherwise exert themselves, their heart rate cannot increase enough to meet their body’s increased demand for blood flow.
This is called chronotropic incompetence.
Chronotropic incompetence can be one of the earliest signs of sinus node dysfunction, a common cause of bradycardia in older adults.
So when deciding whether a heart rate is “too low,” doctors consider both:
- How low the heart rate is at rest
- Whether the heart rate increases appropriately with activity
- Whether the slow heart rate is causing symptoms
What Are the Symptoms of Bradycardia in Older Adults?
When the heart is beating too slowly to provide the blood flow the body needs, symptoms of bradycardia can include:
- Fatigue or low energy
- Dizziness or lightheadedness
- Shortness of breath
- Becoming unusually short-winded with activity
- Reduced ability to exercise or perform usual activities
- Mental clouding or confusion
- Feeling as though you might pass out, known as presyncope
- Fainting, known medically as syncope
Can a slow heart rate cause fatigue?
Yes. Fatigue and reduced exercise tolerance are common symptoms when the heart rate is too slow for the body’s needs.
Some people notice that activities they previously managed easily become much more tiring.
Can bradycardia cause dizziness or falls?
Bradycardia can cause dizziness, near-fainting, and fainting.
In geriatrics, falls can sometimes be part of the picture as well.
For instance, if an older person suddenly falls and cannot clearly explain what happened, it can be worth considering whether they briefly became lightheaded or lost consciousness.
That said, fatigue, dizziness, shortness of breath, confusion, and falls can all have many possible causes in older adults.
So simply finding a slow heart rate does not prove that bradycardia is causing the symptoms.
The important detective work is determining whether the symptoms and the slow heart rate are actually occurring together.
Why Do Slow Heart Rates Become More Common With Aging?
One of the most common reasons older adults develop an abnormally slow heart rate is age-related changes in the heart’s electrical system.
Over time, scar-like tissue can develop in areas involved in generating and transmitting electrical signals.
Eventually, these changes can interfere with the heart’s ability to maintain an appropriate heart rate.
Cardiovascular risk factors such as high blood pressure may contribute to this process.
But aging is not the only possible cause of bradycardia.
Other contributors can include:
- Certain medications, including
- Cardiovascular medications such as beta-blockers and calcium channel blockers
- Medications for irregular heartbeats (e.g. atrial fibrillation) such as amiodarone
- Alzheimer’s medications such as donepezil
- Thyroid problems
- Electrolyte abnormalities
- Certain infections
- Inflammatory illnesses
- Heart surgery or valve procedures that affect electrical conduction
This is important because some causes of a slow heart rate can be reversed without placing a pacemaker.
Sinus Node Dysfunction vs. AV Block: Two Important Causes of Bradycardia
When evaluating bradycardia, doctors try to determine where the problem is occurring in the heart’s electrical system.
Two particularly important causes are sinus node dysfunction and AV block, sometimes called heart block.
What is sinus node dysfunction?
The sinus node is the heart’s natural pacemaker.
When it begins generating electrical signals too slowly, or is unable to increase the heart rate enough when the body needs it, this is called sinus node dysfunction.
You may also hear the older term “sick sinus syndrome.”
Sinus node dysfunction often develops gradually with aging.
Possible symptoms include:
- Low energy
- Fatigue
- Reduced exercise tolerance
- Dizziness
- Falls
- Mental clouding
It is one of the common reasons older adults eventually receive pacemakers.
What is AV block or heart block?
AV block is different.
With AV block, the sinus node may be generating electrical signals normally, but those signals have difficulty reaching the heart’s lower chambers.
In other words, the problem is not necessarily that the electrical signal isn’t being created. Instead, the signal is being blocked as it travels through the heart.
Certain types of AV block can develop more suddenly and can be much more serious than typical sinus node dysfunction.
They may cause:
- Very slow heart rates
- Fainting
- Falls
- Sudden loss of consciousness
Some forms of AV block can be life-threatening and generally require a pacemaker.
How Is Bradycardia Diagnosed?
The tests used to diagnose bradycardia depend on what symptoms are happening and when they occur.
Checking the resting heart rate
A slow heart rate is often first noticed during a routine medical visit.
A pulse oximeter, blood pressure monitor, smartwatch, or other device may also reveal an unusually low heart rate.
If a person’s heart rate used to be higher and has recently become persistently slower, that can be useful information for the healthcare team.
Electrocardiogram or ECG
A standard 12-lead electrocardiogram, also called an ECG or EKG, records the electrical activity of the heart.
An ECG can help doctors determine both how fast the heart is beating and whether the electrical signals are moving through the heart normally.
The limitation is that an ECG only provides a brief snapshot.
If bradycardia or pauses happen intermittently, they might not occur during the few seconds being recorded.
Wearable heart monitors
If symptoms come and go, doctors may recommend wearing a heart rhythm monitor or patch.
These devices can record heart rhythm over several days or weeks.
One of the main goals is to determine what the heart was doing at the time symptoms occurred.
For example, if someone becomes dizzy while walking, doctors can review the recording to determine whether the heart rate became unusually slow at that time.
Exercise or treadmill testing
When symptoms mainly occur with physical activity, exercise testing can be particularly useful.
The person may walk on a treadmill while the heart rate and rhythm are monitored.
This allows doctors to see whether the heart rate rises appropriately during exertion.
If it does not, this may help identify chronotropic incompetence.
Can Medications Cause a Slow Heart Rate?
Yes. Medications are an important and potentially reversible cause of bradycardia, especially in older adults.
Several commonly used heart medications can slow the heart rate.
These include:
- Beta-blockers, such as metoprolol
- Calcium-channel blockers, such as diltiazem
- Digoxin
- Amiodarone and certain other anti-arrhythmic medications
These medications may be prescribed for important reasons, such as atrial fibrillation, heart failure, high blood pressure, or another heart condition.
There are also non-cardiac medications that can cause a slower heart rate in some people, such as donepezil, which is often prescribed for Alzheimer’s and other forms of dementia.
So the answer is not necessarily to stop them.
Instead, the healthcare team should determine whether a medication could be contributing to the slow heart rate and whether the dose or treatment plan can safely be changed.
It is also important to review all medications, not just pills.
For example, beta-blockers are sometimes used as eye drops for glaucoma. Enough of the medication can occasionally be absorbed into the body to slow the heart rate.
So when investigating bradycardia, make sure the healthcare team knows about:
- Prescription medications
- Over-the-counter medications
- Eye drops
- Herbs
- Supplements
What Other Reversible Causes of Bradycardia Should Be Checked?
Before recommending a pacemaker for chronic bradycardia, doctors should consider whether there is a reversible cause.
Depending on the situation, this may include:
- Reviewing and adjusting medications
- Checking thyroid function
- Checking electrolytes
- Looking for certain infections
- Considering inflammatory illnesses
- Considering whether a recent heart procedure temporarily affected the electrical system
If one of these underlying problems can be corrected, the heart rate may improve without requiring a pacemaker.
For chronic sinus node dysfunction, however, there generally isn’t a long-term oral medication that reliably fixes the underlying problem.
When Is a Pacemaker Needed for Bradycardia?
For sinus node dysfunction, pacemaker placement is usually not an emergency.
The key question is:
How likely is the slow heart rate to be causing this person’s symptoms, and how likely is a pacemaker to help?
Doctors may consider questions such as:
- Is fatigue being caused by the low heart rate?
- Is dizziness occurring during episodes of bradycardia?
- Is poor exercise tolerance related to chronotropic incompetence?
- Is the person fainting or nearly fainting because the heart rate is too low?
- Would increasing the heart rate likely improve function or quality of life?
Sometimes the connection between symptoms and bradycardia is clear.
Other times, longer-term monitoring or exercise testing can provide more confidence before a pacemaker is recommended.
When symptomatic bradycardia is due to chronic sinus node dysfunction and reversible causes have been addressed, a pacemaker is generally the main treatment.
Certain forms of AV block are different.
Because serious AV block can be dangerous or life-threatening, a pacemaker may be recommended primarily for safety rather than symptom relief.
Standard vs. Leadless Pacemakers in Older Adults
There are now several ways to provide cardiac pacing.
The right pacemaker depends on the type of electrical problem, the heart’s overall function, and the person’s individual circumstances.
Standard pacemakers
A traditional or transvenous pacemaker generally consists of a small device placed under the skin near the shoulder.
One or more wires, called leads, travel through blood vessels from the device into the heart.
Depending on a person’s needs, the pacemaker may have one or more leads.
A single-chamber pacemaker uses one lead.
A dual-chamber pacemaker generally uses two.
Doctors usually try to choose the simplest device that will adequately meet the person’s needs.
What is a leadless pacemaker?
A leadless pacemaker is a small, self-contained pacemaker placed directly inside the heart.
Rather than making an incision near the shoulder, the device is inserted through a catheter placed into a large vein, usually through the groin.
There is no traditional wire connecting a pacemaker near the shoulder to the heart.
One of the major advantages is a faster and simpler recovery because there are no shoulder-related lead restrictions.
This may be especially useful for older adults who rely heavily on their arms to:
- Push themselves up from a chair
- Use a walker
- Transfer in and out of bed
- Perform other everyday activities
Is a leadless pacemaker better for older adults?
A leadless pacemaker can be a very good option for some older adults, particularly when basic pacing is all that is needed and avoiding shoulder restrictions would make recovery easier.
But it is not automatically better for everyone.
Leadless pacemakers do not provide all the monitoring or pacing capabilities of standard systems, and they cannot always be upgraded in the same way if other heart problems develop later.
The choice should therefore be based on the person’s particular pacing needs and overall health.
What Are Biventricular Pacemakers?
Another type of device is a biventricular pacemaker, also called cardiac resynchronization therapy, or CRT.
This device is generally used for certain people with heart failure.
Rather than simply preventing a slow heart rate, it helps different areas of the heart contract in a more coordinated way.
This can improve the heart’s pumping efficiency in appropriately selected people.
A biventricular pacemaker is therefore different from the standard pacemaker commonly used to treat age-related sinus node dysfunction.
What Is an Implantable Cardioverter Defibrillator?
An implantable cardioverter defibrillator, or ICD, is another implanted heart device that people sometimes confuse with a pacemaker.
An ICD can generally perform pacemaker functions, but it also monitors for certain dangerous fast heart rhythms.
If it detects a life-threatening rhythm, the ICD may first try to stop it using rapid pacing.
If that doesn’t work, it can deliver a much stronger electrical shock to reset the heart’s rhythm.
Unlike ordinary pacemaker stimulation, an ICD shock can be felt.
ICDs may be recommended for people with conditions such as:
- Certain forms of severe heart failure
- Previous ventricular tachycardia
- Previous sudden cardiac arrest requiring resuscitation
Someone who simply has age-related sinus node dysfunction generally does not need an ICD.
What Is Pacemaker Implantation Like?
Pacemaker implantation is generally a relatively short procedure.
Many people can go home the same day, although some spend one night in the hospital.
The procedure itself often takes approximately one to two hours.
A standard pacemaker generally involves a small incision near the shoulder.
A leadless pacemaker is placed through a large vein using a catheter.
Does pacemaker surgery require general anesthesia?
Usually not.
The amount of sedation is individualized, but many people receive conscious sedation or monitored anesthesia care.
This means they continue breathing on their own but receive medication to reduce anxiety, discomfort, and awareness of the procedure.
Is pacemaker implantation painful?
Experiences vary, but most people require relatively little pain medication afterward.
Some need none.
Others may take a few doses of acetaminophen.
It is unusual to need narcotic pain medication after a routine pacemaker procedure, and discomfort usually improves within several days to about a week.
How Long Does It Take to Recover From a Pacemaker?
Recovery depends partly on whether someone receives a standard or leadless pacemaker.
Recovery after a standard pacemaker
After a traditional pacemaker is placed near the shoulder, people are often advised for about six weeks to avoid:
- Raising the arm on the pacemaker side high above the head
- Lifting more than about 10–15 pounds with that arm
The goal is to reduce the risk of pulling one of the newly placed leads out of position.
But this does not mean keeping the arm completely still.
Gentle use is important, especially in older adults, because prolonged lack of shoulder movement can contribute to stiffness or frozen shoulder.
After the initial healing period, most people can return to their usual physical activities.
Recovery after a leadless pacemaker
Recovery after a leadless pacemaker is generally faster.
There are no prolonged arm restrictions because there are no leads running from the shoulder into the heart.
Heavy lifting may still be restricted for about five to seven days while the catheter insertion site heals.
For some older adults, this easier recovery is an important advantage.
What Is It Like to Live With a Pacemaker?
For most people, the goal of a pacemaker is to allow them to return to ordinary life with relatively few restrictions.
How pacemakers are monitored
Most modern pacemakers can be monitored remotely.
People may receive a small device that communicates with the pacemaker and sends information to their healthcare team.
Some systems can also use a smartphone app.
Remote monitoring can provide information about:
- Heart-rate patterns
- How often the pacemaker is pacing
- Certain abnormal rhythms
- Battery status
- How well the device is functioning
Changing the pacemaker’s settings generally requires an in-person visit.
How long does a pacemaker battery last?
Pacemaker batteries often last roughly 7–10 years, although this varies depending on the device and how much pacing is required.
The battery is monitored over time, so replacement can generally be planned well before it runs out.
For a standard pacemaker, replacement often involves reopening the small area near the shoulder, disconnecting the old generator from the existing leads, and connecting a new device.
If the leads do not need to be changed, recovery is usually easier than after the original implantation.
For leadless pacemakers, the options may include removing and replacing the device or placing a new device alongside it, depending on the particular system.
Can You Travel, Have an MRI, and Use Household Devices With a Pacemaker?
After the initial recovery period, most people with pacemakers can return to ordinary activities.
People are usually given an identification card listing the pacemaker model and other important information.
It is useful to keep this card available when traveling or receiving medical care.
Ordinary household appliances generally do not pose a problem.
Many newer pacemakers also allow MRI scanning under specified conditions.
However, anyone with a pacemaker should always tell the healthcare team about the device before having an MRI or another medical procedure so that the specific model and precautions can be checked.
Can Someone in Their 90s Get a Pacemaker?
Yes. Advanced age by itself does not automatically rule out a pacemaker.
A more useful question is whether the pacemaker is likely to provide meaningful benefit for that particular person.
For an older adult with symptomatic sinus node dysfunction, improving the heart rate may help with:
- Fatigue
- Dizziness
- Falls
- Reduced mobility
- Poor exercise tolerance
- Mental clouding
In some very old adults, correcting significant bradycardia can noticeably improve function and quality of life.
The decision should be based on overall health, expected benefit, procedural burden, and the person’s preferences — not simply chronological age.
Should Someone With Dementia Get a Pacemaker?
Having Alzheimer’s disease or another form of dementia does not automatically mean a pacemaker is inappropriate.
The important question remains:
What benefit are we hoping the pacemaker will provide, and how likely is it to provide that benefit?
In someone with memory problems, it can be harder to determine whether symptoms such as fatigue, reduced activity, or mental clouding are actually being caused by bradycardia.
That can make the decision less certain.
Still, if there is good reason to believe the slow heart rate is causing significant symptoms, a pacemaker may improve function or quality of life.
The decision should consider:
- How likely bradycardia is to be causing symptoms
- What improvement can realistically be expected
- The risks and burdens of the procedure
- The person’s frailty and other health conditions
- How difficult recovery would be
- The person’s goals and preferences
For some frail older adults or people with memory problems, the shorter recovery associated with a leadless pacemaker may also be worth discussing.
Does a Pacemaker Extend Life?
The answer depends on why the pacemaker is needed.
For typical sinus node dysfunction, the main benefit is often improved symptoms, function, and quality of life.
Sinus node dysfunction is generally not immediately life-threatening.
Certain forms of AV block are different.
If electrical signals can no longer reliably reach the ventricles, a pacemaker can potentially be life-saving.
Some people are also pacemaker-dependent, meaning they rely heavily on the device to maintain an adequate heartbeat.
But most people with pacemakers are not completely pacemaker-dependent.
What Happens to a Pacemaker at the End of Life?
Pacemakers can be turned off, but this is not routinely necessary for most people approaching the end of life.
One reason is that most people are not fully pacemaker-dependent.
Another is that a pacemaker can continue to support comfort and function without necessarily preventing the natural dying process.
A pacemaker does not mean that a person cannot die naturally when the rest of the body is shutting down.
The situation is somewhat different with an ICD.
Because an ICD can deliver a strong electrical shock in response to certain dangerous fast heart rhythms, people approaching the end of life sometimes choose to have the shock function turned off.
If the ICD is also providing necessary pacing, the pacing function can remain active while the shock function is deactivated.
These decisions should reflect the person’s goals, values, and overall plan of care.
Questions to Ask Your Healthcare Provider About Bradycardia and Pacemakers
If you or an older person you care about has been diagnosed with bradycardia or has been advised to consider a pacemaker, here are some useful questions to ask:
- Could there be a reversible cause of the slow heart rate?
- Could any medications be contributing?
Be sure to review prescription medications, over-the-counter drugs, eye drops, herbs, and supplements.
- How sure are we that my symptoms are being caused by bradycardia?
- Would additional heart monitoring or exercise testing help?
- Is this sinus node dysfunction, AV block, or another electrical problem?
- What benefit do you expect a pacemaker to provide in my situation?
- What type of pacemaker would be most appropriate?
- Would a leadless pacemaker be an option?
- Do I need an echocardiogram to assess my heart function before choosing a device?
- What will recovery involve given my mobility, frailty, and other health conditions?
The Bottom Line on Slow Heart Rates and Pacemakers in Older Adults
A slow heart rate becomes increasingly common with aging, but not every heart rate below 60 requires treatment.
What matters most is whether the heart is beating fast enough to meet the body’s needs.
Bradycardia can cause fatigue, dizziness, shortness of breath, reduced exercise tolerance, confusion, near-fainting, fainting, and sometimes falls.
Doctors may use an ECG, longer-term heart monitoring, or exercise testing to determine whether the slow heart rate is actually responsible for a person’s symptoms. They should also look for potentially reversible causes, especially medications, thyroid problems, electrolyte abnormalities, and certain illnesses.
When persistent bradycardia is due to sinus node dysfunction and is causing symptoms, a pacemaker can be a very effective treatment.
Pacemaker implantation is generally a relatively straightforward procedure, and newer leadless pacemakers may offer an easier recovery for some older adults.
For someone who is very old, frail, or living with dementia, the decision should ultimately come back to one of the most important principles in geriatrics:
Is this treatment likely to help this person feel better, function better, and receive care that is consistent with what matters most to them?
