Hypertension is the most important risk factor for cardiovascular events in the elderly and it is present in more than 50% of acculturated populations over 60 years of age. Morbidity trials have clearly demonstrated the benefits of treating hypertension in the elderly in all subgroups examined, including diabetics, those over 80 years of age, those with or without electrocardiographic abnormalities, and in both men and women. These reductions in strokes, coronary events, and other hypertensive complications have been seen primarily with diuretic-based regimens, with or without potassium-sparing therapy. However, in the 1990s physicians are initiating diuretics less often for older patients with hypertension in spite of this scientific evidence. Low doses of diuretics have been well tolerated, successful in recent morbidity trials, and avoid much of the concerns about theoretical toxicities from diuretics, although higher doses have also been shown to reduce cardiovascular events. Until calcium channel blockers, angiotensin converting enzyme inhibitors, alpha-blockers, or some other class of antihypertensive agent has been demonstrated to be at least as effective as diuretics in reducing cardiovascular events or mortality, diuretics should be the first drug class to consider for the treatment of hypertension in the elderly.