Atrial fibrillation is an extremely rare cause of falls and syncope in the elderly. The routine use of ambulatory ECG monitoring to search for atrial fibrillation in elderly patients who fall is not recommended. Among elderly patients with atrial fibrillation who fall, short pauses of less than 3 seconds are nonspecific and are as common in patients who fall as they are in those who do not. Furthermore, most pauses are not associated with symptoms. Although the decision to implant a pacemaker for extremely long pauses is often straightforward, the decision to implant a pacemaker in patients who fall and who have short pauses ideally should be made after symptoms clearly have been associated with the dysrhythmia. This type of symptom-rhythm correlation is extremely valuable and often requires long-term ambulatory monitoring with external or internal (implanted) event or loop recorders. Among the growing population of elderly persons with chronic atrial fibrillation, oral anticoagulant therapy has been shown to have significant benefit and is underused, particularly in frail residents of long-term care facilities. The published literature does not support the commonly held belief that a patient's propensity to fall is an important factor in determining optimal antithrombotic therapy. Demographic shifts in the worldwide population continue to alter the practice of medicine, which is being influenced increasingly by the health care needs of the expanding elderly population. Additional research is needed to clarify the relationship between atrial fibrillation and falls in the elderly.