This review examines pharmacotherapy of rhythm management for atrial fibrillation (AF) in the elderly. There is little research specifically focused on this topic in the elderly but five of the seven randomized controlled trials comparing pharmacologic rate control to pharmacologic rhythm control enrolled patients who can be considered “elderly”. Collectively, these studies showed that the rate control approach was favored for the outcomes of mortality, hospitalization and cost. With respect to stroke and systemic thromboembolism, no clear advantage accrues to either approach and the major therapeutic intervention for stroke prevention is anticoagulation. Rhythm control may be better for relief of symptoms in those who are highly symptomatic but symptoms are usually less problematic in the elderly. Little comparative information is available about use of specific drugs in the elderly but beta blockers are probably the preferred initial therapy for rate control when possible. Although amiodarone is the most effective rhythm control agent, its adverse effect profile suggests it should be reserved for use when other antiarrhythmic drugs fail or are contraindicated. To date, “upstream” or preventive therapies have not been specifically evaluated in the elderly but nebivolol (a beta blocker) does not prevent emergence of AF in elderly patients with heart failure, although it does provide the other salutary benefits of beta blocker therapy seen in younger heart failure patients.