Background New-onset seizures are frequently encountered in community and hospital settings. It is likely that seizures presenting in these distinct settings have different etiologies and prognoses, requiring different investigation and treatment approaches. We directly compare the presentation and management of patients with community- and hospital-onset first seizures attending the same hospital.Methods We reviewed the medical records of patients aged 18 years or older with discharge International Classification of Diseases, Australian Classification (ICD-10-AM) codes of G40 (epilepsy), G41 (status epilepticus), and R56.8 (unspecified convulsions), who attended a general hospital in Melbourne, Australia, from January 1, 2008, through November 30, 2016. Patients with new-onset seizures were included for analysis.Results A total of 367 patients were discharged with a relevant ICD-10-AM code. Among them, 151 patients met the inclusion criteria: 97 presented to the emergency department with community-onset seizure (median age 70 years), and 54 experienced seizures during hospitalization for other indications (median age 80.5 years). Provoked seizures were more common in the latter group (26.8% vs 63.0%, p < 0.001), with exposure to proconvulsant drugs a major risk factor. Despite not fulfilling the International League Against Epilepsy (ILAE) diagnostic criteria, 72.5% (58/80) who survived to discharge were prescribed antiepileptic drug (AED) therapy, whereas 19.0% (12/63) of those who met the ILAE criteria were not.Conclusions Hospitalized elderly patients are at an increased risk of provoked seizures, and caution should be exercised when prescribing potential proconvulsant medications and procedures. A more standardized approach to AED prescribing is needed. Further studies should consider morbidity, mortality, and health economic effects of first seizures and assess optimal management to improve outcomes in this cohort.