Sinus node disease and atrioventricular block are common etiologies of symptomatic bradyarrhythmias in the elderly and remain the leading indications for permanent pacemaker implantation. In fact, the vast majority (>80%) of all pacemakers are implanted in the elderly. Whereas indications of pacemaker therapy have been largely unchanged over the past several years, several questions, such as differences in pacemaker mode selection, remained unanswered. Recent large, randomized, multicenter trials have evaluated the benefits of pacemaker therapy in sinus node dysfunction and acquired atrioventricular block and have provided us with further insights into the difference between atrial- and ventricular-based pacing in these syndromes. Further evaluation of the most appropriate pacing mode in the elderly as well as the outcome of pacing in the elderly are addressed in this review.