Syncope is a common and often recurrent clinical problem in elderly patients. Frequently, the precise etiology of recurrent syncope in the elderly remains unclear despite repeated diagnostic testing. This leads to frustration, not only for patients and family members, but also for the treating physician. In many cases, the cause of syncope in the elderly is multifactorial. Recurrent episodes necessitate repeated hospitalization and lead to considerable morbidity and increased cost. Despite these diagnostic problems, however, most episodes of syncope in elderly patients can be classified as cardiogenic or noncardiogenic on the basis of a thorough history and careful physical examination. Cardiogenic causes can be further divided into reflex, orthostatic, and primary cardiac disorders, allowing for more focused diagnostic testing. In this review, the etiology, pathophysiology, and distinguishing clinical features of syncope in the elderly, as well as current therapeutic strategies in patients with recurrent syncope, are discussed. (c)1999 by CVRR, Inc.