Aging is associated with multiple physiological changes that significantly influence anesthetic management and perioperative outcomes in elderly patients. Cardiovascular alterations, including decreased cardiac compliance, increased arterial stiffness, and reduced baroreceptor sensitivity, contribute to hemodynamic instability and increased susceptibility to intraoperative hypotension. Respiratory changes such as reduced lung elasticity and diminished pulmonary reserve increase the risk of hypoxemia and postoperative pulmonary complications. In addition, age-related declines in renal and hepatic function affect drug metabolism and elimination, increasing the likelihood of anesthetic drug accumulation and toxicity. Structural and neurochemical changes in the central nervous system further increase sensitivity to sedatives and anesthetic agents, predisposing older adults to postoperative neurocognitive complications. Pharmacokinetic and pharmacodynamic modifications associated with aging require careful adjustment of anesthetic drug dosing. Evidence indicates that the requirements for agents such as propofol and remimazolam decrease significantly with age, emphasizing the importance of dose titration to avoid excessive sedation and hemodynamic instability. At the same time, polypharmacy is highly prevalent among elderly patients and increases the risk of clinically significant drug–drug interactions, particularly with cardiovascular and central nervous system medications. Thorough preoperative medication reconciliation and careful drug selection are therefore essential components of perioperative risk reduction. Postoperative delirium remains one of the most common and clinically significant complications in elderly surgical patients, with reported incidences ranging from 11.1% to 45.6%. This condition is associated with increased mortality, prolonged hospitalization, and greater postoperative morbidity. Preventive strategies include comprehensive geriatric assessment, optimization of comorbidities, careful intraoperative monitoring, multimodal analgesia, and minimization of sedative medications. A multidisciplinary approach that integrates individualized anesthetic planning, appropriate pharmacological management, and targeted delirium prevention strategies is essential to improve perioperative safety and outcomes in elderly patients.