BACKGROUND: The number of very elderly persons who are candidates for implantation of a permanent pacemaker is increasing, but the effect of cardiac pacing on long-term survival and functional variables has not been determined. OBJECTIVE: To determine long-term survival after implantation of a permanent pacemaker in octogenarians and nonagenarians and to assess functional independence after such implantation. DESIGN: Retrospective, population-based cohort study. SETTING: Epidemiologic setting from an unselected population. PATIENTS: 157 octogenarians and nonagenarians who initially received a pacemaker between 1962 and 1988 and were followed through 1992. MAIN OUTCOME MEASURES: Overall mortality rate, functional capabilities, and placement in a nursing home. RESULTS: Observed survival in patients with heart disease was significantly worse than that in age-and sex-matched controls (P < 0.001). Observed survival in community residents without heart disease was similar to that in controls (P > 0.2). Multivariable analysis identified congestive heart failure, chronic obstructive pulmonary disease, old age, syncope, cancer, and atrioventricular block as independent predictors of increased mortality. Symptoms decreased in 118 patients (75%) after pacemaker implantation. After implantation, 70 patients (45%) were permanently placed in nursing homes; this number is similar to the estimated probability of lifetime use of nursing homes from the National Mortality Followback Survey. Dementia developed or worsened in 51 patients (32%), and orthopedic disability occurred in 41 patients (26%). CONCLUSIONS: Normal relative survival in octogenarians and nonagenarians without heart disease is reassuring; the poor prognosis in patients with heart disease warrants careful evaluation of the methods and indications for cardiac pacing. Permanent pacing alleviates bradycardia-related symptoms. Placement in a nursing home and development or worsening of cardiac, neurologic, or orthopedic disabilities frequently occur after implantation of a permanent pacemaker in the very elderly.