Introduction: it has previously been reported that patients aged over 65 years account for 15% of Accident and Emergency (A&E) attendances. Despite this, there have been few studies looking at older people's use of A&E. This study describes the A&E attendance patterns of older people, defined as those aged 65 years and over, using data from an NHS region over a number of years. Their attendances are also compared with those of the rest of the population. Data and methods: A&E attendance data were collected for 14 Acute Trusts in the West Midlands for the period from 1 April 1999 to 31 March 2002 via the West Midlands Accident and Emergency Surveillance Centre. Results: patients aged 65 years and over accounted for 18% of all attendances. Attendance rates were highest in those aged over 80 years. Older patients were significantly more likely to attend during the morning and early afternoon, during the winter months, arrive by ambulance and require admission to hospital. Older patients were significantly more likely to attend with non-injury, particularly cardiac-related conditions. Injuries accounted for 33.1% of attendances in the over-65s compared with 59.9% in the 0–64s. Conclusions: this study is the first in England to look at the A&E attendance patterns of all older people in an NHS region. It has demonstrated the continued high level use of A&E by those aged over 65 years. This highlights the need for continued systemic monitoring of A&E attendance patterns to enable planners to accommodate the impact of the increasingly ageing population.