Untreated patients aged ≥60 with aplastic anemia (AA) have a poor prognosis, with inferior treatment outcomes. Old age, per se, is not a contraindication to treating a patient. In contrast to younger patients, the treatment decision-making process is not only based on disease-related factors but also on functional ability, comorbidity, and social support, which need to be evaluated carefully. In case of eligibility to treat, immunosuppression is the first-line treatment option. Depending on the urgency to obtain a hematological response (i.e., severe neutropenia or active infections), treatment should start with either the combination of anti-thymocyte globulin (ATG), cyclosporine (CSA), and eltrombopag, or an ATG-free treatment with the combination of CSA with or without eltrombopag. There is no place for hematopoietic stem cell transplantation (HCT) as a first-line option, unless using syngeneic HCT. For refractory or relapsed patients after immunosuppressive treatment (IST), second-line treatment with other immunosuppressive drugs or HCT, provided they are eligible, should be considered. In this chapter, we aim to provide some guidance on how to approach the treatment of elderly patients with aplastic anemia.