Bladder cancer is a disease that predominantly effects the elderly and as this patient population continues to rapidly increase, it is becoming a major health problem. A significant proportion of elderly patients with bladder cancer have muscle-invasive disease. Physiologic changes associated with aging predispose elderly patients to increased surgical perioperative morbidity and mortality, yet radical cystectomy remains the standard of care for muscle-invasive bladder cancer in the USA. Therefore, it is crucial to not only assess the functional status and fragility level of these patients prior to operative intervention, but also to consider factors that may preclude them from being able to adequately care for a urinary diversion. In addition, the risks and benefits of neoadjuvant or adjuvant chemotherapy must be carefully considered and tailored to the individual patient. In this review, we discuss treatment options for elderly patients with muscle-invasive disease and analyze tools for predicting perioperative morbidity and mortality. Finally, we examine the use of chemotherapy in this patient population.