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Delusional disorder in older adults is a diagnosis of exclusion, necessitating comprehensive evaluation before a diagnosis can be made. It is characterized by the presence of a fixed and circumscribed delusion but in contrast to schizophrenia, there are no other psychotic symptoms. It is often accompanied by cognitive deficits in working memory and attention, with increased risk for progressive cognitive decline. Patients with delusional disorder suffer from increased rates of major depression, placing them at increased risk for suicide. While data are limited, the best available evidence suggests that patients benefit from combined treatment strategies that include an atypical antipsychotic and cognitive–behavioral therapy.