Electroconvulsive therapy (ECT) is an important therapeutic modality in geriatric patients because its safety, high efficacy and rapid onset of action are suited to the special needs of this population. It appears that ECT can be effective in the acute treatment of depression, mania, paranoid disorders and various psychiatric syndromes occurring in the context of brain disease. Certain cardiovascular and neurological disorders or use of drugs increase the risk of ECT in geriatric patients. Clinical strategies for evaluating and reducing the ECT risk in such cases are presented and directions for future clinical research are discussed.