Abstract Objective To consider the characteristics of first episode psychosis in older adults in a county in North East England. Method/Design The present study used a naturalistic design to compare individuals aged 65 years and over with those under 65, with a first episode psychosis. Data were collected on demographics, diagnosis at presentation and hospital admissions in the first year. Results Almost a quarter of all patients were aged 65 years or older. The older group were admitted later on after presentation, but with longer average hospital stays (p < 0.01), compared to the younger group, with no difference in the use of the Mental Health Act. Late onset schizophrenia (40–59 years) and very late onset schizophrenia‐like psychosis (60 + years) formed a considerable proportion of patients. Conclusions There is a substantial proportion of older people with first episode psychosis, with a significant use of hospital bed days. There are large gaps in services for this group who often do not have the same access to those offered to younger people, e.g. Assertive Outreach or crisis teams, access to Clozapine and CBT. Ageism exists in all forms; the elderly are doubly disadvantaged in view of their age and mental illness. In view of the Age Discrimination Act (2006) the elderly functionally ill group of patients should be entitled to the same level of care and equal access to services as younger people. More attention and interventions need to be focused on this overlooked group. © Crown copyright 2009. Reproduced with the permission of Her Majesty's Stationery Office. Published by John Wiley & Sons, Ltd.