Objective: “Epilepsy in the elderly (EE)” is considered a homogeneous, benign syndrome in patients aged > 60 years, with cerebrovascular disease as the most frequent etiology. We challenge this concept by comparing EE and middle-aged adults with epilepsy (MAE). Methods: We compared: 1) seizure dynamics, 2) MRI lesions, 3) EEG findings and 4) treatment course in EE and MAE at the Halifax First Seizure Clinic. Results: 48 EE patients aged > 60.2 years (median 66.9 years). 31 MAE patients aged 50.2 – 59.6 years (median 55.1 years). Seizure dynamics in EE/MAE included first seizure in 50/54.8%, new onset epilepsy (new seizures within 12 months) in 43.8/35.5%, newly diagnosed epilepsy (seizures for >> 12 months) in 9.6/6.3%. First seizure evolved into new onset epilepsy in 12.5/3.2%. MRI in EE/MAE was normal in 22.5/27.6% or showed microangiopathy (25/38.5%), atrophy (10/15.4%), tumors (7.5/11.5%), vascular malformations (7.5/3.8%), hippocampal pathologies (0/3.8%), infarcts (12.5/0%). EEG in EE/MAE was normal in 64.4/65.5% or showed diffuse (6.6/3.5%) or focal slowing (8.8/7%), generalized (4.3/13.7%) or focal (15.4/10.4%) epileptiform activity. At 12 months, 87% of EE and 93.8% of MAE were seizure-free. Conclusions: EE and MAE show similar heterogeneity. We propose an etiology-driven classification of epilepsy syndromes in the aging brain.