Osteoporosis management in older people should be aimed at fracture prevention. Most trial evidence involving antiosteoporotic medications in reducing fragility fractures exists in women up to the age of 80 years. In this review we discuss the management of osteoporosis in the very elderly, those over the age of 80, focusing on the evidence for anti-resorptive and anabolic agents in reducing fragility fractures in this particular age group.