The prevalence of rheumatoid arthritis (RA) in an aging population is steadily increasing as a consequence of the chronicity of the disease and the increased life expectancy. The phenotype of the disease differs according to the age at which RA first appears. In elderly-onset RA (EORA), the most important differential diagnosis is polymyalgia rheumatica. The use of conventional disease-modifying antirheumatic drugs (DMARDs) and biologicals in older patients is currently not optimal. Literature data indicate that a higher disease activity in this age group is tolerated before adapting the pharmacotherapeutic management. Yet, there is no indication that the safety and efficacy of RA-specific drugs are essentially different between older and younger patients. An important criterion for making a decision is the biological age of the person to be treated. A discrepancy between the biological and the chronological age may be caused by frailty, multimorbidity and the presence of geriatric giant conditions (cognitive limitations, depression, sensory disorders, disturbed mobility and incontinence). In case of a favourable biological age, a sharp therapeutic target should be formulated and pharmacotherapy should be designed to reach such a target. If a person ages less successfully with an unfavourable biological age, drugs with a safety risk should be prescribed with more restraint and more safety surveillance. Non-pharmacotherapeutic care (exercise therapy, occupational therapy), in addition to drug therapy, has an important role for older patients with RA.