Cardiomyopathies are an important cause of congestive heart failure in the elderly, and the magnitude of the problem is compounded by changing population demographics and the frequency of congestive heart failure in the elderly. Although the data are far from complete, differences in the clinical presentations and natural history of the cardiomyopathies in older and younger patients are becoming more clearly appreciated. Dilated cardiomyopathy (DCM) is clearly more common than previously appreciated, and elderly patients have a worse prognosis than their younger counterparts with this disease. The medical management of DCM is often more difficult in the elderly, and the problem is compounded by the relatively infrequent use of cardiac transplantation as a therapeutic option. Hypertrophic cardiomyopathy is also more common than previously appreciated, and changes in left ventricular structure often create difficulties in differentiating pathologic states from physiologic. Fortunately, the prognosis for HOCM is more favorable in the elderly than in younger patients and may be partly accounted for by the different structure of the left ventricle. If needed, surgery is an option for elderly patients with medically refractory HOCM, but particular attention must be paid to the presence and severity of associated cardiovascular disease. Restrictive cardiomyopathy with diastolic dysfunction is increasingly recognized as a cause of congestive heart failure. The differentiation from systolic dysfunction is crucial, because the treatments are so markedly different. Age-related changes in diastolic function are becoming more apparent and better characterized, but standardization of age-related "normal" values is still not available. The diagnosis of restrictive heart disease should stimulate a search for an underlying cause, inasmuch as restrictive cardiomyopathy remains a diagnosis of exclusion. Advances in noninvasive imaging have led to a resurgence of interest and have enhanced our knowledge of the cardiomyopathies. Further investigation should proceed in conjunction with studies aimed at defining the characteristics and variables of "normal" aging. For the present, the enigmatic, poorly identified "cardiomyopathies" remain a problem for both young and old.