Falls occur in approximately 30% of older adults each year, and about 30% of these falls are caused by syncope. The most common causes of syncope in the elderly are upright hypotension, carotid sinus hypersensitivity, reflex syncope, and cardiac arrhythmias. Syncope due to aortic stenosis, pulmonary embolism, or arrhythmias with a cardiac basis occurs more frequently in the elderly than in younger people. The clinical manifestations of syncope in elderly patients are varied and often atypical. The presence of age-related degenerative changes in elderly patients often predicts the onset of syncope. Physiologic changes and multiple medications taken by elderly patients are risk factors for the development of reduced upright tolerance and syncope. Coexisting cardiac disease, pathological gait, abnormalities in cardiovascular function regulation, recurrent falls, and upright hypotension are age-related. The presence of a blunted central response to thirst, use of vasodilators, diuretics, and other emergencies in the elderly predisposes to hypovolemia, which leads to postural hypotension and induces syncope. Orthostatic hypotension is common in elderly patients and is the causative agent in 33% of elderly syncope patients. Carotid sinus hypersensitivity is an easily overlooked cause of syncope in elderly patients. Neurally mediated syncope plays a large role in the pathogenesis of elderly patients, but is often overlooked because of its atypical clinical presentation. In addition, nearly half of the syncopal episodes in the elderly are associated with applied cardiovascular medications. The occurrence of clinically unexplained syncope in the elderly is often the first manifestation of certain neurodegenerative diseases, such as: Parkinson’s disease. Typical clinical manifestations of neuroreflex syncope are difficult to see in elderly patients. In addition, 40% of patients with syncope in advanced age are accompanied by complete amnesia. The goal of the diagnostic evaluation of patients with syncope in advanced age is to exclude life-threatening diseases as well as to prevent recurrent falls. Upright hypotension and changes in heart rate should also be addressed aggressively.