The incidence of peptic ulcer and its severe complications, i.e. bleeding or perforation, is increasing in elderly patients worldwide. The prevalence of Helicobacter pylori infection in patients with peptic ulcer aged over 65 years has been reported to range from 58 to 78%. However, in elderly patients hospitalised for ulcer disease, the rate of diagnostic screening or treatment for H. pylori infection was less than 60%, and only 50 to 73% of patients who had a positive H. pylori test were treated with antibacterials. The eradication of H. pylori infection is known to be of proven benefit for elderly patients with H. pylori-associated ulcer disease. Significant improvement of the clinical outcome, and reduction of ulcer recurrences, symptoms and histological signs of ulcer-associated chronic gastritis activity, as well as decreased costs in elderly healthcare, all result from successful therapy. Proton pump inhibitor (PPI)-based triple therapy regimens including clarithromycin, amoxicillin and/or nitroimidazoles are highly effective and well tolerated in elderly patients, particularly if therapy is of a short duration and low doses of both the PPI and clarithromycin are used. Resistance of H. pylori to antibacterials and low compliance are the major reasons for treatment failure. Surveillance of H. pylori susceptibility to antibacterials at the regional level and enhanced compliance programmes give promising results that suggest new approaches to anti-H. pylori treatment, especially in elderly patients. The role of H. pylori infection in nonsteroidal anti-inflammatory drug (NSAID)-related peptic ulcer still remains controversial. At present, no clear evidence supports the testing and treatment of H. pylori infection for the prevention of drug-related peptic ulcer in elderly patients receiving an NSAID or aspirin (acetylsalicylic acid). After therapy, elderly patients with peptic ulcer may be re-evaluated by invasive methods, i.e. endoscopy and gastric biopsies. or by noninvasive methods. In elderly patients, the 13C-urea breath test demonstrated significantly higher sensitivity, specificity and diagnostic accuracy for detecting H. pylori infection than anti-H. pylori antibodies.