The treatment of type 2 diabetes in the elderly represents a major challenge both in terms of clinical management and public health. Aging is causing a marked increase in the pandemic of diabetes in elderly people. However, scientific evidence to support the most appropriate treatment for diabetes in the elderly is scarce. Given the heterogeneity of the elderly population, which includes subjects with very different functional and cognitive capacities, co-morbidities, and life expectancy, it is critical to make a comprehensive assessment from a biopsychosocial perspective, to address the vascular risk factors integrally, and to establish individually tailored targets for glycemic control. In frail elderly people or individuals with a short life expectancy, it may be reasonable to maintain HbA1c between 7.6% and 8.5%. The therapeutic strategy for elderly patients with type 2 diabetes should be individualized and agreed on with the patient and their caregivers, according to the objective. Improving quality of life, assuring patient safety and avoiding the adverse effects of anti-diabetic treatment should be prioritized. Given the increased susceptibility of the elderly to severe hypoglycemia and its consequences, anti-diabetic therapies that minimize the risk of hypoglycemic events should be selected.