Background An increasing number of older people with schizophrenia are living in the community but we still have little data on their clinical presentation, service use and functioning. Methods All patients over the age of 60 years with a primary diagnosis of a non-affective psychotic disorder who were known to health services were identified in a rural area of East England. Subjects were interviewed with the Present State Examination and other standardised interview instruments. Results Seventy-two subjects fulfilled study inclusion criteria. Forty-six of these had first become ill before the age of 60 years and 26 after (the very late onset group (VLO)). Eighty per cent were women and 26% had never married. Eighty-seven per cent lived in their own homes and 51% alone. In the preceding month, 41% of the sample had experienced psychotic symptoms and 15% depressive symptoms. Twenty-seven per cent of the sample were cognitively impaired. The earlier onset group had significantly higher rates of tardive dyskinesia and negative symptoms of schizophrenia and were treated with higher doses of neuroleptics. The VLO group had higher rates of hearing impairment (54% vs 15% p = 0.001) and of partial or no insight (93% vs 55% p = 0.004). Conclusions Despite significant differences in presentation, elderly patients with schizophrenia and very late onset schizophrenia-like psychosis have much in common. Both groups are vulnerable with high levels of psychopathology, poor insight, sensory impairment and social isolation. The needs of older people with schizophrenia must be taken into account when services for older adults are planned. Copyright (C) 2004 John Wiley Sons, Ltd.