Modern medicine has bolstered the life expectancy among older adults, which now averages around 80 years of age in developed nations. Older adults currently make up nearly 17% of the US population, with a projected rise to 25% of all adults in the coming decades. Older adults currently account for almost 50% of all surgical procedures performed in the USA, where overall health-related expenditures comprised 17.4% of the national GDP. The stress of surgery can be exacerbated with advancing age and is primarily determined by the preoperative physiological reserve and comorbid conditions. Any additional postoperative clinical challenges can significantly affect the stress response and ultimate recovery trajectory. This chapter systematically emphasizes the perioperative strategies to counteract the inadequate surgical stress response resulting from the age-related challenges in maintaining homeostasis. Unique preoperative considerations when evaluating older adults include: cognition, functional status frailty, care goals, advance directives, nutritional status, polypharmacy, and cardiopulmonary optimization with “prehabilitation” when possible. Optimization of the preoperative evaluation coupled with a preemptive postoperative approach to decrease the risk of delirium, falls, malnutrition, infections, pressure sores, aspiration, and other pulmonary complications, along with early mobilization and therapy, can yield the best possible outcomes in this population.