In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.