Acute vestibular syndrome (AVS) is one of the most common causes of sudden vertigo in elderly patients and represents a serious clinical challenge due to the high risk of a central origin, particularly ischemic stroke in the vertebrobasilar circulation. Age-related changes, multimorbidity, and cognitive impairment complicate clinical assessment and may lead to delays in diagnosis and treatment. Objective: to evaluate the characteristics of the course of acute vestibular syndrome in elderly patients, taking into account age-related, vascular, and cognitive factors. Materials and methods. A prospective clinical study included 76 patients aged 60–82 years with acute vestibular syndrome who were treated as inpatients between 2018 and 2025. All patients underwent a detailed neurological and otoneurological examination using the HINTS protocol, assessment of balance and gait, evaluation of vertigo severity using the Dizziness Handicap Inventory (DHI), neuroimaging (CT/MRI), and cognitive screening with the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Patients were divided into age groups for comparative analysis. Results. With increasing age, there was a significant rise in the severity of clinical manifestations of AVS, the frequency of central etiology, and ischemic changes detected by neuroimaging. In patients aged ≥75 years, signs of central involvement according to the HINTS protocol and mild cognitive impairment were more frequently observed. Delayed hospital admission was associated with more severe vertigo and slower functional recovery. Conclusion. The course of acute vestibular syndrome in elderly patients is determined by a combination of age-related, vascular, and cognitive factors. Mandatory use of bedside diagnostic methods, early neuroimaging, and a comprehensive, individualized treatment approach are key to improving patient safety and preserving functional independence in the elderly.