Half of all pacemakers implanted in the United States are for patients aged 75 years and older. The expectations and needs of an older group are different from patients who are younger, yet it is only recently that different pacing mode benefits for elderly persons have been tested in clinical trials. Some of the results have been surprising and suggest new algorithms for management. Other issues are still on the threshold of investigation. These include pacing for heart failure in elderly patients and pacing combined with cardioverter-defibrillator implantation.