Altered mental state (AMS) is a common presentation in the elderly to the emergency department. It has been determined that about 16% of patients aged 60 or older with confusion of unknown origin had non-convulsive status epilepticus (NCSE). The diagnosis of NCSE is difficult in the elderly because possible etiologies of confusion could present with the same clinical picture. NCSE in the elderly carries major morbidity and mortality, attributable primarily to the etiology. Treatment of NCSE in the elderly is complex, involving treatment of the etiology and concomitant medical illnesses, whilst balancing the side effects and drug interactions of antiepileptic drugs. A review of the recent literature had been undertaken to look at the studies done on elderly patients with confusion of unknown origin or altered mental states that used an electroencephalogram (EEG) in the workup of these patients, and considered the differential diagnosis of NCSE. At this point, there are many unanswered questions. There needs to be a prospective study to determine the prevalence of NCSE specifically in the elderly patients who present with AMS consecutively. There probably is a need to look at the prevalence of NCSE due to specific etiologies in the elderly. There is a need to identify clinical features in these elderly patients which would predict NCSE with adequate sensitivity and specificity. There is also a need to develop management guidelines on timing, duration and cost effectiveness of emergency EEG in the context of investigating these elderly patients who present with AMS. In an ideal scenario, elderly patients with AMS could have an array of investigations done routinely in the emergency department without delay. NCSE could be picked up on the initial emergent EEG, and together with other neuro-imaging and biochemistry investigations, work out the etiology of the NCSE, and then decide on the appropriate treatment. The treatment plan could be analyzed for risk and benefits with the aid of a decision analysis tool.