Late-onset forms of psychosis have been the object of increasing interest in recent years. Despite the fact that there are still many obscure areas, significant advances in the pathophysiology, delimitation of risk factors, clinical presentation, neuropsychology and the pharmacological treatment have been made. Nevertheless, the psychological aspects of both aetiology and treatment of these late forms of psychosis have received much less attention than the rest. In contrast with that, the clinician is confronted with the need to manage patients that are reluctant to take medications and in which the outcome of pharmacological treatments is not always optimal. The elderly psychotic patient should not be excluded from the possibility of receiving any kind of psychological help. He may benefit from adaptations of different psychotherapeutic measures that can include the more classical techniques as psychodynamic oriented and behavioural-cognitive therapies or the newer forms of treatment specially designed for the aged, as reminiscence or psychomotor therapy. In any case, to obtain any result the patient needs to be managed in a way that goes well further the prescription of a neuroleptic drug. In this paper we review some of the most important psychological cues for the understanding of the elderly psychotic patient. Furthermore, we divide the therapeutic relationship over the time in three parts: The initial contact, the central phase and the termination. We offer some keys for the practical management of the patient in each of these phases, with special attention to the adherence to treatment and early identification of treatment-emergent complications like depressive symptoms or hypochondriac concerns.