The present review, building on a previous review published in 1993, gives a general overview of a large subject. As on the previous occasion, it is primarily concerned with the assessment of risk and the improvement of outcome in the older surgical patient. However, some of the previously-discussed technical difficulties of assessing risk, which apply to a wide range of medical and surgical specialties, have not been repeated this time. Updates have been given on cardiac, respiratory and nutritional risk assessment in older surgical patients, and a section on post-operative changes in mental function has been added. The use of new outcome measures, including the measurement of quality of life, is also discussed more fully in the present review.