The demand for elective and emergency surgery by older patients is increasing. This review examines the current practice of preoperative evaluation in geriatric anesthesia and provides an overview of new insights in this field. Preoperative anesthesia consultation is essential to examine the patient, evaluate the operative risk and plan preventive perioperative actions. Chronological age probably represents an independent risk factor. Age should not be considered an exclusion criterion from surgery per se. More than 50% of patients over 70 years old suffer from one infirmity, and 30% suffer from two or more infirmities. Hypertension is the most common disease, followed by coronary artery disease, diabetes and chronic obstructive pulmonary disease. Aging processes, illnesses, malnutrition, difficulties in communication and comprehension, psychological alterations and social needs may coexist and overlap. Changes in pharmacodynamics and pharmacokinetics induced by aging make elderly patients very sensitive to drugs, especially those administered perioperatively. Drug underuse, misuse and abuse are described, together with criteria to manage perioperative medications. Disability, dementia and frailty are risk factors for adverse outcomes and delirium after surgery. Traditional anesthesia consultation captures only a small portion of the necessary information, especially about functional status and frailty. Although the association between older age and surgical complications is well known, most anesthetists and surgeons do not measure physical and cognitive function preoperatively. Extending anesthesia consultation to functional status provides useful information for preoperative counseling and planning of postoperative care. A strong joint action with the surgical team is essential. Currently, while many resources are employed to assess preoperative cardiac risk and despite the dramatic increase in the number of elderly surgical patients, the association between older age itself and surgical complications has not been fully investigated, and preoperative evaluation of functional status is not yet a part of routine preoperative practice. Creating a new culture and developing appropriate clinical, scientific and relational approaches to these patients represent the core of the challenge.