The number of older individuals with multiple sclerosis is steadily increasing, encompassing both those with late-onset multiple sclerosis and those experiencing long-term disease progression from earlier diagnoses. Late-onset multiple sclerosis (LOMS) refers to disease onset after the age of 50, while very-late-onset multiple sclerosis (VLOMS) is defined as onset after the age of 60. It is estimated that late-onset multiple sclerosis accounts for approximately 1.1–21.3% of patients, while 0.6–3.6% of multiple sclerosis cases are very-late-onset. Late-onset multiple sclerosis usually has a primary progressive course, and the first symptoms are pyramidal in 60–70% cases. The specific characteristics of multiple sclerosis in this population are influenced by immunosenescence and brain aging processes. Managing multiple sclerosis in older patients requires meticulous differential diagnosis and close monitoring, considering the impact of comorbidities and other age-related factors. Therapeutic decisions should be highly individualised, striking a balance between the efficacy and safety of available treatments. Given the limited data on optimal multiple sclerosis management in this demographic, further observational studies are essential. This review presents the current state of knowledge needed for understanding and effectively treating multiple sclerosis in older age.