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Objectives: To evaluate the prevalence of cognitive impairment (CI), including mild CI and dementia, in elderly patients with syncope and unexplained falls. In this population, we compared the use of the Mini-Mental State Examination (MMSE) with a cognitive screening test that assesses executive dysfunction typical of subcortical (vascular) CI, that is, the Montreal Cognitive Assessment (MoCA)., Design: Observational cohort study., Setting: Outpatient fall and syncope clinic., Participants: Consecutive patients aged ≥65 years with syncope and unexplained falls without loss of consciousness., Measurements: Baseline characteristics, functional status, MMSE, MoCA, and magnetic resonance imaging scans of the brain., Main Outcome: prevalence of CI, comparing the MMSE with the MoCA. CI was defined as an MMSE/MoCA score <26., Secondary Outcomes: MMSE/MoCA overall and subdomain scores, Fazekas and medial temporal lobe atrophy scores., Results: We included 200 patients, mean age 79.5 (standard deviation 6.6) years (Syncope Group: n = 101; Fall Group: n = 99). Prevalence of CI was 16.8% (MMSE) versus 60.4% (MoCA) in the Syncope Group (P < .001) and 16.8% (MMSE) versus 56.6% (MoCA) in the Fall Group (P < .001). Prevalence of CI did not differ between the Syncope Group and Fall Group with either method. Executive dysfunction was present in both groups., Conclusion: CI is as common in elderly patients with syncope as it is in patients with unexplained falls, with an overall prevalence of 58%. The MMSE fails as a screening instrument for CI in these patients, because it does not assess executive function. Therefore, we recommend the MoCA for cognitive screening in older patients with syncope and unexplained falls., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)