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As population aging accelerates, patients aged ≥ 75 years represent a growing proportion of those diagnosed with ampullary tumors. Endoscopic papillectomy (EP) is an established minimally invasive treatment for ampullary adenoma; however, treatment selection in older patients requires careful consideration of oncologic benefit, procedural risk, geriatric vulnerability, and life expectancy. This review outlines key geriatric assessment tools and evaluates the safety, prognosis, and treatment selection of endoscopic and surgical approaches for ampullary tumors in older patients. With appropriate selection, short-term EP outcomes appear comparable between older and younger patients. However, EP can cause fatal adverse events and often requires long-term surveillance or retreatment. In older patients, long-term prognosis is strongly influenced by comorbidity burden and competing mortality, with a high age-adjusted Charlson Comorbidity Index associated with poorer overall survival. Natural history data from familial adenomatous polyposis and colorectal adenomas provide an indirect time-axis framework for considering surveillance in selected high-risk patients. Management of ampullary tumors in older patients should be guided by integrated assessment of oncologic and geriatric factors rather than chronological age alone. Standardized geriatric assessment may help identify patients best suited for intervention or surveillance. Prospective studies incorporating functional outcomes, quality of life, and treatment-related mortality are needed to support evidence-based decision-making.