The vast majority of cardiac pacemakers are implanted in older people. Pacing is a safe and effective treatment for patients with symptomatic bradyarrhythmias. This review provides a clinician's guide to the essential aspects of modern pacemaker therapy in older patients, including aetiology and epidemiology of bradycardia. We discuss some barriers to access to pacing. We review indications for pacemakers, and describe pacing system function, including the different types of pacemakers used. We also review clinical outcomes following pacing, follow-up requirements and problems encountered in clinical practice. Finally, we discuss ethical and end of life considerations with these devices.