{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T12:39:04Z","timestamp":1786711144120,"version":"build-2736575974"},"reference-count":45,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T00:00:00Z","timestamp":1786665600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Syncope in older adults is common, heterogeneous, and frequently misclassified as an unexplained fall, leading to injury, fear of recurrence, and costly, low-yield testing and hospitalization. The 2018 European Society of Cardiology (ESC) Guidelines emphasize structured initial evaluation (history with witnesses, orthostatic blood pressure, and 12-lead ECG), risk-feature-guided disposition, and targeted second-line investigations rather than routine neuroimaging or carotid duplex ultrasound. We performed a structured narrative review anchored to the ESC 2018 Guidelines, searching MEDLINE\/PubMed up to February 2026 for randomized trials, observational cohorts, and systematic reviews with substantial representation of adults aged \u226565 years and extracting geriatric-relevant outcomes including injury, falls, admission, arrhythmic diagnoses, and short-term serious events. Evidence since 2018 supports the enduring value of the ESC 2018 Guidelines\u2019 framework but highlights the need for geriatric adaptation: repeated orthostatic phenotyping (including post-prandial and delayed hypotension), systematic deprescribing, and explicit integration of frailty, cognition, and trauma risk into disposition decisions. Post-2018 data strengthen mechanism-based strategies, including earlier implantable loop recorders with remote monitoring and selective pacing for tilt-induced asystolic reflex syncope, while cardioneuroablation remains investigational for most elders. We propose a pragmatic pathway prioritizing diagnostic yield, minimizing low-value testing, and aligning interventions with patient goals and functional outcomes to reduce recurrences and support safer transitions.<\/jats:p>","DOI":"10.3390\/jcm15166303","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T11:57:46Z","timestamp":1786708666000},"page":"6303","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Management of Syncope in Geriatric Patients: Are 2018 European Society of Cardiology Guidelines Still Relevant?"],"prefix":"10.3390","volume":"15","author":[{"given":"Barbara","family":"Antonazzo","sequence":"first","affiliation":[{"name":"Division of Geriatrics, Israelite Hospital, 00148 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-3568-0743","authenticated-orcid":false,"given":"Anna","family":"Sirignano","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Santa Maria Goretti Hospital, 04100 Latina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martina","family":"Salvini","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Surgery, Sapienza University of Rome, 04100 Latina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-0408-9855","authenticated-orcid":false,"given":"Francesca Flavia","family":"Rossi","sequence":"additional","affiliation":[{"name":"Division of Geriatrics, Israelite Hospital, 00148 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Ronzoni","sequence":"additional","affiliation":[{"name":"Division of Geriatrics, Israelite Hospital, 00148 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agnese","family":"Dorizzi","sequence":"additional","affiliation":[{"name":"Division of Geriatrics, Israelite Hospital, 00148 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8527-569X","authenticated-orcid":false,"given":"Kenneth","family":"Ellenbogen","sequence":"additional","affiliation":[{"name":"Division of Cardiology, VCU School of Medicine, Richmond, VA 23298, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6103-8510","authenticated-orcid":false,"given":"Giuseppe","family":"Biondi-Zoccai","sequence":"additional","affiliation":[{"name":"Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy"},{"name":"IRCCS Maria Cecilia Hospital\u2014GVM Care & Research, 48033 Cotignola, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0129-471X","authenticated-orcid":false,"given":"Simone","family":"Calcagno","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Department of Emergency and Admission, San Paolo Hospital, Largo Donatori del Sangue 1, 00053 Civitavecchia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"afad245","DOI":"10.1093\/ageing\/afad245","article-title":"Syncope in older adults: Challenges, approach and treatment","volume":"53","author":"Jansen","year":"2024","journal-title":"Age Ageing"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"867","DOI":"10.1093\/europace\/eux099","article-title":"Multiple causes of syncope in the elderly: Diagnostic outcomes of a Dutch multidisciplinary syncope pathway","volume":"20","author":"Wold","year":"2018","journal-title":"Europace"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1093\/eurheartj\/ehy037","article-title":"2018 ESC Guidelines for the diagnosis and management of syncope","volume":"39","author":"Brignole","year":"2018","journal-title":"Eur. 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