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Hypertension is most prevalent in the elderly population and a major source of morbidity and mortality. After the age of 50 years, systolic pressure continues to rise and diastolic pressure tends to fall leading to the predominance of isolated systolic hypertension (ISH). Systolic blood pressure is the main determinant of risk and should be the target of drug therapy. Lowering blood pressure in the elderly tends to decrease the incidence of stroke, heart failure and myocardial infarction. Life style and dietary modifications, in addition to low sodium diet help achieve blood pressure goals. In the absence of a compelling indication, a low dose thiazide diuretic or a long-acting dihydropyridine calcium channel blocker are appropriate first line therapies. Inhibitors of the Renin-Angiotensin-Aldosterone System (RAAS) are appropriate alternatives and could be added or substituted. β blockers may not be appropriate as monotherapy or first line treatment. Combination therapy is frequently needed and the use of low dose combinations may help reduce adverse effects. Goals of therapy may be similar to those in younger populations, although achieving blood pressure goals may be challenging.