Purpose: Acute Gallstone Disease (AGD) increases with age. With co-morbidities and frailty, older adults may deteriorate rapidly, necessitating time-critical decision making. Although laparoscopic cholecystectomy (LC) is often the definitive initial management, percutaneous cholecystostomy (PC), endoscopic retrograde cholangiography (ERCP), or antibiotics alone may be utilised. The aim of this study is to describe the management of AGD in older adults and explore associated outcomes. Methodology: A retrospective analysis of older adults with AGD was undertaken from May 2021 to September 2022 at a tertiary hospital in WA. Descriptive statistics and logistic regression were used for data analysis. Results: Of 122 older adults with AGD the average age was 78, average CFS was 4, and average CCI was 5. Admitting diagnoses were acute cholecystitis (54.1%), choledocholithiasis (10.66%), cholangitis (30.33%), and gallstone pancreatitis(4.92%). 19.7% had LC, 12.3% had PC, 34.3% had ERCP, and 32% were treated with antibiotics alone. Mortality was lowest post LC and highest post PC (0% vs 13.3%, p = 0.03). Readmission at ninety days was highest following antibiotic treatment alone (25.6%,) and PC (20%, p = 0. 004). 46.7% of patients were readmitted within two years after PC versus 4.2% post LC. Conclusions: LC is a safe and effective operation in managing AGD in older adults, with no post operative mortalities. Management with PC and antibiotics alone were associated with increased readmissions. Periprocedural decision making in AGD should include procedural and anaesthetic risk and recurrence and readmission rates, in the context of patient preferences, frailty and medical co-morbidities.