Background: Obstructive sleep apnea (OSA) is associated with an increased risk of major cardiac and cerebrovascular events (MACCE). However, data on the burden and predictors of MACCE in geriatric patients with OSA (G-OSA) remain limited. Methods: Using the National Inpatient Sample from 2018, we identified G-OSA admissions (age ≥ 65 years) and divided them into non-MACCE vs. MACCE (all-cause mortality, stroke, acute myocardial infarction, and cardiac arrest). We compared the demographics and comorbidities in both cohorts and extracted the odds ratio (multivariate analysis) of MACCE and associated in-hospital mortality. Results: Out of 1,141,120 geriatric obstructive sleep apnea G-OSA admissions, 9.9% (113,295) had MACCE. Males, Asians, or the Pacific Islander/Native American race, and patients from the lowest income quartile revealed a higher MACCE rate. Significant clinical predictors of MACCE in elderly OSA patients on multivariable regression analysis in decreasing odds were pulmonary circulation disease (OR 1.47, 95% CI 1.31–1.66), coagulopathy (OR 1.43, 95% CI 1.35–1.50), peripheral vascular disease (OR 1.34, 95% CI 1.28–1.40), prior sudden cardiac arrest (OR 1.34, 95% CI 1.11–1.62), prior myocardial infarction (OR 1.27, 95% CI 1.22–1.33), fluid and electrolyte imbalances (OR 1.25, 95% CI 1.20–1.29), male sex (OR 1.22, 95% CI-1.18–1.26), hyperlipidemia (OR 1.20, 95% CI 1.16–1.24), low household income (OR 1.19, CI 1.13–1.26), renal failure (OR 1.15, 95% CI 1.12–1.19), diabetes (OR 1.14, 95% CI 1.10–1.17), metastatic cancer (OR 1.14, 95% CI 1.03–1.25), and prior stroke or TIA (OR 1.12, 95% CI 1.07–1.17) (All p value < 0.05). Conclusions: This study emphasizes the significant association between obstructive sleep apnea (OSA) and major cardiac and cerebrovascular events (MACCE) in the geriatric population. Among the elderly OSA patients, a substantial 9.9% were found to have MACCE, with specific demographics like males, Asian or Pacific Islander/Native American individuals, and those from the lowest income quartile being particularly vulnerable. The study sheds light on several significant clinical predictors, with pulmonary circulation disease, coagulopathy, and peripheral vascular disease topping the list. The highlighted predictors provide valuable insights for clinicians, allowing for better risk stratification and targeted interventions in this vulnerable patient cohort. Further research is essential to validate these findings and inform how tailored therapeutic approaches for geriatric OSA patients can mitigate MACCE risk. Clinical Implications: Elderly individuals with a high risk for MACCE should undergo routine OSA screening using tools like the sensitive STOP-BANG Questionnaire. Implementing CPAP treatment can enhance cardiovascular outcomes in these patients.