Aims: To quantify complication rates in elderly cochlear implant (CI) recipients compared with younger adults and characterise age-related patterns, including very elderly patients aged ≥80 years. Methodology: MEDLINE, Embase, CINAHL, Web of Science and CENTRAL were searched from database inception to August 2025. Observational studies of adult CI recipients reporting post-operative complications stratified by age (≥65, ≥70, ≥75, ≥80 years) were included. Of 3,472 records screened, 40 studies encompassing 5,897 patients aged ≥65 years (including 2,136 aged ≥75, and 1,149 aged ≥80) were analysed. Anaesthetic, device related and major/minor surgical complications were analysed. Results: For patients ≥65 years, major complications occurred in 7.4% versus 1.4% (p<0.0001), minor complications in 16.3% versus 4.7% (p<0.0001), and risks of re-admission, extended or ICU admission in 2.5% (p=0.003). For patients ≥75 years, major complications increased to 10.1% versus 7.2% in <75yo CI recipients (p=0.024). Of ≥75yo CI recipients, 7.0% reported a fall in the 30-day post-operative window. Among octogenarians, major complication rates were comparable to patients aged <75yo (7.9% versus 7.3%, p=0.65), yet risks of re-admission, prolonged hospital stay or ICU admission remained elevated (4.1% versus 0.6%, p<0.0001). Octogenarians had the highest rate of minor complications (19.5 versus 8.1%, p<0.0001). Anaesthetic arrhythmias and postoperative delirium were strongly over-represented in this cohort. Conclusion: As the population ages, and profound hearing loss becomes more prevalent, the number of patients who will benefit from cochlear implantation will grow. This is the first systematic review to focus on complication rates specifically in the elderly cohort. These findings support CI candidacy in carefully selected elderly patients while informing pre-operative frailty assessment, peri-operative planning and patient counselling regarding age-specific risk profiles.