The incidence of stroke increases dramatically with advancing age. Progressive carotid atherosclerosis, cardiac arrhythmia and emboli, and vascular changes all contribute to this increasing incidence of stroke in the elderly. Treatment of hypertension and other risk factors have resulted in a decline in stroke over the last 50 years. The decline has been most prominent in the elderly. In recent years, this decline has slowed down or may even be reversing. Early and effective control of risk factors together with comprehensive management of acute stroke in a specialized unit is needed to further improve prognosis. Such an approach is especially important in the elderly, who may suffer from multiple problems. Treatment of hypertension and other risk factors have resulted in a decrease in an overall decline in the incidence of stroke over the last 50 years. This decline has been most apparent in the elderly. In recent years, however, there has been a slowing or possibly a reversal of this trend. Early and effective management of risk factors, aggressive therapy of patients with transient ischemic attacks and comprehensive management of acute stroke patients in specialized units may be required to further improve prognosis.