Purpose of Review <p>Acute cholecystitis (AC) is a potentially life-threatening condition whose incidence increases with age. Given the progressive increase in life expectancy, the number of elderly patients presenting with AC is expected to rise. The aim of this review is to analyze the current state of the art and future perspectives regarding management strategies and potential complications in elderly patients.</p> Recent Findings <p>Currently, there is still no clear consensus in terms of guidelines for the management of AC in the elderly. Older patients undergo conservative treatment more frequently than younger individuals. However, an increasing number of studies have demonstrated the feasibility and safety of operative management, including laparoscopic cholecystectomy, although it remains associated with higher mortality and morbidity rates compared with younger populations.</p> Summary <p>Patients who are fit for surgery should undergo laparoscopic cholecystectomy, whereas those unfit for surgery should be managed conservatively and, in selected cases, with percutaneous cholecystostomy. Rather than chronological age alone, comorbidities and patient frailty are emerging as the most relevant factors for predicting mortality, overall complications, and readmission rates. Management of AC in elderly patients should therefore be considered a risk-stratified decision-making process rather than a binary choice between operative and non-operative management.</p>