The amount of fat surrounding the heart, called epicardial adipose tissue (EAT), is a marker of cardiometabolic risk and correlates with the quantity of visceral adipose tissue (VAT). The amount of VAT is associated to an increased risk of cardiovascular and cerebro-vascular disease and with cognitive impairment. We aimed to evaluate the association between EAT thickness as a measure of VAT and cognitive function. In 71 elderly subjects (mean age 72.7±7.1 years) we measured EAT thickness by trans-thoracic echocardiography, assessed the metabolic profile through evaluation of biochemical parameters and genetic determinants (IRS2 genotype), and estimated the cognitive function via the Mini Mental State Examination (MMSE). We found that greater EAT thickness was associated with lower cognitive performance evaluated by MMSE (p < 0.01) independently of the presence or absence of metabolic syndrome or obesity. Lower MMSE results were also associated with increasing age (p < 0.01), presence of metabolic syndrome (p < 0.01), elevated HOMA index (p < 0.01), high fasting plasma glucose (p < 0.01), high BMI values (p < 0.01), as well as high total and LDL cholesterol (p < 0.01). IRS2 genotype was associated to MMSE results with a suggestion of a dominant effect. In conclusion, increased EAT thickness assessed by transthoracic echocardiography is associated with deficient results of psychometric tests assessing cognitive performance, and may consistently foresee impairment of cognition in the elderly.