The geriatric trauma patient poses unique challenges to the trauma surgeon due to occult injuries and occult hypoperfusion. We hypothesized that those elderly patients with significant injuries, who were not initially evaluated via trauma activation, would suffer worse outcomes. All cases of elderly (age ≥ 65) admitted to the trauma service from the years 2000 to 2010 were included. Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined patients as undertriaged (UT) if they had an ISS > 15 and did not undergo a trauma team activation, but had a regular workup by an emergency department physician and trauma team consultation. Factors that contributed to being UT in the emergency department were investigated by univariate and multivariate analysis. A total of 4534 elderly patients constitute this analysis, of which 15.1 per cent were UT. The UT patients were more likely to die, when adjusted for Revised Trauma Score, Glasgow Coma score, the occurrence of ≥1 complication, and whether the patient was on Coumadin. UT has a high risk of death in elderly patients. Trauma triage guidelines need to be better tailored to identify the high-risk geriatric trauma patient.