While the overall incidence of venous thrombosis is 1–2 per 1000 per year, it is close to 1% per year in the very old. The case–fatality rate of thrombosis is high in the elderly, particularly among those with cancer. The risk of major hemorrhage during anticoagulant treatment is also strongly age‐dependent, contributing to the vulnerability of the old patient with thrombosis. From this perspective it is surprising that far fewer studies into the etiology and treatment of venous thrombosis have focused on the elderly than on young and middle‐aged patients. In this review we discuss that, while environmental risk factors, such as immobilization and cancer, are important causes of thrombosis in the elderly, abnormalities of the coagulation system are equally, or even more, important than in young individuals. In addition to a review of the literature, new data are presented from the MEGA‐study. Thrombosis in the elderly should be a focus of future studies.