As people live longer, an increasing proportion of patients with schizophrenia and delusional disorder will be elderly. Little has been published on treatment response, effective treatment strategies, or the use of atypical neuroleptics in this group. This review of the literature explores documented response rate, route and dose of neuroleptic, indicators of poor response, and the use of novel drugs. Despite great variation in the neuroleptic dose ranges employed, patients with late-onset disease often continue to experience psychotic symptoms. Compliance with treatment is the most important determinant of outcome. Atypical neuroleptics are specifically indicated for patients with visual hallucinations or extrapyramidal symptoms. Elderly psychotic patients should be treated as vigorously and with as wide a range of neuroleptics as their younger counterparts. Physicians should not restrict drug doses to modest levels in all cases as long as patients are monitored frequently for the emergence of side effects.