Rheumatoid arthritis (RA) increases in incidence and prevalence with age, with a peak in the sixth decade of life. Elderly onset RA (EORA) may be genetically different from younger onset RA, and with immune dysfunction associated with aging, environmental factors may also influence EORA onset. Smoking, periodontitis and viral infections are examples of environmental factors that have been shown to be associated with development of EORA, and even hormonal changes with menopause may be a source of RA activation in older patients. EORA can be distinguished from polymyalgia rheumatica, inflammatory hand osteoarthritis or psoriatic arthritis by rheumatoid factor or anticitrullinated protein antibodies. Comorbidities influence treatment risk–benefit and require proactive management; these include arteriosclerotic cardiovascular disease, obesity, diabetes, GI tract conditions, lung disease, renal disease or malignancies, as well as susceptibility to infection. As inclusion of older RA patients is lower in clinical trials, safety data in this group are limited and this influences treatment choice, especially for biologics. Despite the efficacy of biologics, they are less likely to be used in older RA patients. This is problematic as glucocorticoids, when used in the elderly, are associated with serious infections, cardiovascular and fracture risk, among other side effects. Similarly, analgesics and NSAIDs should be used cautiously. Taking into account comorbidities, treat-to-target strategies with nonbiologic disease-modifying antirheumatic drugs and biologics can be applied with an expectation of acceptable risk–benefit in these patients.