Acute appendicitis remains one of the most common surgical emergencies worldwide; however, its presentation, diagnosis, and management in elderly patients differ considerably from those in younger populations. Elderly individuals frequently exhibit atypical clinical manifestations, delayed presentation, multiple comorbidities, and reduced physiological reserve, all of which contribute to higher rates of perforation, postoperative complications, prolonged hospitalization, and mortality. Advances in diagnostic imaging, minimally invasive surgery, perioperative care, and risk stratification have significantly improved outcomes in this population. The role of non-operative management with antibiotics remains controversial, particularly given concerns regarding recurrence, missed neoplasms, and delayed definitive treatment. This review examines current evidence regarding the treatment options and outcomes of acute appendicitis in the elderly. Emphasis is placed on the role of non-operative treatment and appendectomy in the management of acute appendicitis in the elderly. We will also look at the role of laparoscopic appendectomy in the management of acute appendicitis in the elderly. Understanding the unique characteristics of appendicitis in elderly patients is essential for improving diagnostic accuracy, reducing complications, and optimizing clinical outcomes.