With the advent of sensitive brain imaging techniques, white matter lesions are commonly observed in healthy as well as in demented elderly people. Primarily vascular risk factors have been related to the presence of white matter lesions, such as hypertension, atherosclerosis and atrial fibrillation. Subcortical white matter lesions are mainly associated with depression in the elderly, while periventricular lesions are clearly associated with cognitive dysfunction. Current evidence on the relation between vascular risk factors, white matter lesions and cognition is based on cross-sectional studies. Prospective studies are needed to confirm causality and to study the efficacy of treatment of vascular risk factors.