This paper summarizes the evidence supporting the pharmacological treatment of hypertension in the elderly as well as some the remaining controversies. The world is becoming progressively older and with that, the prevalence of hypertension is increasing. A peculiar form of hypertension, most prevalent among the elderly, is isolated systolic hypertension (ISH). Hypertension in the elderly, especially when systolic blood pressure (SBP) exceeds 160 mm Hg should be treated. Lowering the SBP to less than 150 mm Hg confers substantial cardiovascular protection. This has been demonstrated in both older and newer drugs for ISH and systolo-diastolic hypertension and is beneficial in both younger individuals (60-79 years) and uncomplicated elderly (80+ years) individuals suffering from hypertension. However, a number of issues remain controversial. Firstly, the 140 mm Hg cut-off for SBP cannot be applied to all age groups. It is conceivable that lowering the SBP below 140mm Hg in some patients, particularly in the elderly may not be beneficial. Hence, the generalizations made in clinical trials should be approached with caution. Additionally some drugs, such as beta-blockers, thiazide diuretics may be associated with significantly less benefit in the elderly patients. More research is needed, especially in the areas where we lack data: the first stage of uncomplicated ISH or hypertension in the elderly with associated co-morbidities.