Thrombocytopenia in the elderly is a common but diagnostically challenging condition that has variable clinical impact to those affected. Diagnostic approach requires evaluation of pre-existing clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. We describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an elderly population. The first addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second addresses complications of thrombocytopenia in management of the myelodysplastic syndrome (MDS). The last reviews diagnostic challenges of drug induced immune thrombocytopenia (DITP).