Background: Cochlear implantation (CI) is increasingly offered to older adults with severe-to-profound hearing loss, yet age-specific perioperative risks remain incompletely characterized. This systematic review and meta-analysis aimed to quantify perioperative complication rates among CI recipients aged 65 years and compare these with rates in younger adults. Methods: Following a prospectively registered protocol (PROSPERO CRD420251207956), we searched MEDLINE, Embase, CINAHL, Scopus and Web of Science through 18 November 2025. Eligible studies reported complications in adults aged 65 years, included 10 elderly recipients, and had 30 days’ follow-up. Random-effects meta-analyses estimated absolute risks in elderly cohorts and relative risks (RR) versus younger adults, stratified by age thresholds (65, 70, 75, and 80 years). Results: Forty-one studies (6,374 elderly and 5,904 younger recipients) were included. No perioperative mortality was reported. In recipients aged 65 years, the pooled incidence of major complications was 2.4% (95% CI 1.7–3.4%), minor complications were 22.3% (95% CI 16.1–30.0%), and anaesthetic complications were 3.1% (95% CI 2.2–4.3%). Device-related complications occurred in 4.2% of recipients. Comparisons against younger cohorts suggested elderly recipients face increased relative risk for minor surgical (RR 1.6, 95% CI 1.0–2.6) and anaesthetic complications (RR 4.6, 95% CI 2.0–10.5), though these were not robust to sensitivity analysis. Persistent vertigo rates ranged from 6–8.5% across strata, and falls showed potential age-related increases at thresholds 70 years. Conclusion: CI in the elderly is associated with low absolute rates of major surgical complications. While minor and anaesthetic events are more frequent than in younger cohorts, absolute risks remain modest. These findings emphasize the importance of thorough anaesthetic assessment and the monitoring of vestibular symptoms and fall risk in very elderly candidates.