As global life expectancy increases and innovative, minimally invasive techniques are more common, older adults represent a rapidly growing patient demographic undergoing surgical procedures. Age-related physiological changes, frailty and multimorbidity present unique perioperative challenges that demand a patient-centred, multidisciplinary approach to anaesthesia. This chapter explores the impact of ageing on key organ systems, highlighting their implications for anaesthetic management. It outlines essential pharmacokinetic and pharmacodynamic considerations, emphasising the need for tailored drug dosing and careful monitoring to minimise complications. Preoperative assessment strategies, including frailty and cognitive function evaluation, are also discussed to optimise patient outcomes and facilitate shared decision-making. Evidence-based recommendations for anaesthetic technique, intraoperative monitoring and postoperative care are provided to enhance perioperative safety and mitigate risks such as postoperative neurocognitive disorders and haemodynamic instability. By integrating these principles, clinicians can better navigate the complexities of anaesthesia in older adults, ensuring safer and more effective perioperative care.