Considerable research has focused on alcohol problems in older adults, but the clinical utilization of this knowledge has lagged at least 3 decades behind the scientific developments. This unfortunate situation takes on added significance as the "baby boomer" generation ages because more of them drink more often in larger quantities than previous generations. This chapter focuses more on the ramifications of use, misuse, and abuse than on chronic dependence because the prevalence in the former categories far outweighs the latter. Older alcohol misusers and abusers are at excess risk for myriad physical problems and premature death because alcohol interacts with the natural aging process in negative ways to increase risks for injuries, hypertension, cardiac dysrhythmic events, cancers, gastrointestinal problems, neurocognitive deficits, bone loss, and emotional challenges, most notably depression. Low volume and less than daily alcohol consumption appear to be protective against blood clots in the coronary and brain vessels, bone loss and falls, and cognitive decline compared with current abstainers. At higher levels, alcohol has the opposite effect. Research findings strongly support positive outcomes of case finding, referral, and treatment of older adults who are misusing or abusing alcohol. However, there is ample evidence that health care providers across the spectrum of primary, acute, and long-term care ignore the signs and symptoms of alcohol misuse and abuse in their older patients and treat symptoms and sequelae of the abuse rather than confronting the abuse itself. Recommendations for changes in practice are made together with ideas for additional research in several areas where the current state of knowledge is inadequate, conflicting, or based on narrowly homogeneous samples.