Old age is the most common time in life to develop epilepsy.1 Making a secure diagnosis can be difficult, and piecing together an accurate picture of events may take some time. The clinical manifestations of seizures, the causes of epilepsy, and the psychosocial impact of the diagnosis can be different in older people than in younger ones. In addition, elderly people with epilepsy have two to three times higher mortality than the general population.w1 Age related physiological changes can affect the pharmacokinetics and pharmacodynamics of antiepileptic drugs. The situation is compounded by a paucity of good clinical studies. In this review we discuss the challenges and highlight recent developments in the diagnosis and management of epilepsy in elderly people. We searched Medline, Embase, and the Cochrane Collaboration with the key words “epilepsy”, “seizures”, “elderly”, “aged”, and “anticonvulsants”. We selected articles of interest from 1995 onwards and then hand searched these for earlier publications, focusing on those that specifically included elderly patients and covered clinically relevant topics. More than 11 million elderly people live in the United Kingdom, at least 1% of whom will have epilepsy. Compared with younger populations, elderly people are more prone to develop seizures, whether provoked by acute illnesses (“provoked” or “acute symptomatic” seizures) or without an obvious immediate cause (“unprovoked” seizures). Thirty per cent of acute seizures in elderly people will present as status epilepticus,w2 which carries a mortality approaching 40%.w3 The annual incidence of epilepsy (recurrent unprovoked seizures) rises from 90 per 100 000 in people between the ages of 65 and 69 to more than 150 per 100 000 for those over 80 (fig 1).2w4 With continuing ageing of the population, the number of older people with epilepsy is set to rise further, placing an increasing burden …