Neurosurgical patients are aging as the general population is becoming older. A retrospective review of patients ≥65 years of age who underwent an elective craniotomy from 2007 to 2015 to identify risk factors for 30-day morbidity/mortality was conducted. Key preoperative variables included age, comorbidities, and functional status based on the Karnofsky Performance Status score and modified Rankin Scale score. Outcome variables included long-term care (LTC) complications, neurologic complications, systemic/infectious complications, length of stay, functional outcomes, and mortality. A total of 286 patients ≥65 years underwent elective craniotomy at Loyola University Medical Center over 8 years. Seventy-two patients had a preoperative neurologic deficit and 95 had a systemic morbidity before surgery. Postoperative neurologic and systemic morbidity was 14% and 23%, respectively. 7% of patients experienced a LTC complication and 5 patients (1.7%) died. Worse preoperative scores on both the Karnofsky Performance Status and modified Rankin Scale predicted increased length of stay and mortality (P < 0.05). Univariable and multivariable analyses showed that patients with preoperative motor deficit, altered mental status, congestive heart failure, smoking history, and chronic steroid use were all more likely to have an LTC complication, and increased anesthesia time and estimated blood loss increased risk for LTC, neurologic, and systemic/infectious complications. This study identifies factors that predict perioperative complications for elderly patients undergoing elective craniotomies, particularly congestive heart failure, smoking history, chronic steroid use, anesthesia time, and estimated blood loss. Age alone should not preclude elective craniotomy.