The proportion of elderly individuals in the population is on the rise, and hypertension is extremely common in this age group. In addition, the cardiovascular and cerebrovascular risks associated with elevated blood pressure levels are greater in the elderly than in their younger counterparts. Systolic hypertension accounts for >50% of hypertensive cases in the elderly, probably as a result of arterial stiffening and loss of arterial compliance that occurs with aging. Large-scale, controlled, randomized trials have provided conclusive evidence that reduction of elevated blood pressure levels in the elderly safely and effectively decreases cerebrovascular and cardiovascular morbidity and mortality rates. The benefit of antihypertensive therapy in decreasing the incidence of stroke, myocardial infarction, and left ventricular failure has also been demonstrated to apply to patients with isolated systolic hypertension. Because the risks associated with untreated hypertension are greater in older than in younger patients, and the relative gains associated with treatment in the two groups are comparable, antihypertensive treatment is actually more cost-effective in the elderly population. Issues that remain to be resolved in future studies include which antihypertensive agents are most appropriate for use in older patients and whether it is appropriate to treat so-called stage I isolated systolic hypertension. (Am Heart J 1998;135:S2-S7.)