Oral anticoagulants have documented efficacy for many indications and are widely used in elderly patients. However, there is concern about whether this treatment induces an excess of major bleeding in elderly patients. In this systematic review, the incidence of oral anticoagulant-related major bleeding among elderly patients was determined. A total of 58 reports were identified that evaluated an oral anticoagulant, included patients with a mean age of at least 60 years, and provided data on the occurrence of major bleeding or provided separate data on the occurrence of major bleeding in elderly versus younger patients. In 50 studies no age differentiation was given. Although the incidence of bleeding complications varied, a trend towards increased bleeding with increasing age was shown in patients with major orthopaedic surgery and cardiac diseases. In the 8 articles that provided separate data on the occurrence of bleeding in different age categories, there was a clear tendency towards a 2-fold increase in bleeding in elderly patients. These findings emphasise the need for caution in the use of oral anticoagulants in elderly patients. However, the decision to start oral anticoagulant treatment should be based on an evaluation of the risk/benefit balance on a careful patient-by-patient basis. In general, if oral anticoagulant treatment is started, the lowest possible effective International Normalised Ratios (INR) should be selected and regular monitoring should be done to avoid over-anticoagulation.