OBJECTIVE To assess elderly individuals' demand for emergency department (ED) care, in terms of the characteristics, processes, outcomes, costs by referral pattern. DATA SOURCE All ED visits involving patients aged 65 and older, extracted from the 2010 dataset of an Local Health Agency, in North-Eastern Italy (no. = 18 648). STUDY DESIGN Retrospective cohort study. PRINCIPAL FINDINGS Patients were referred by primary care professionals (PCPs) in 43.1% of cases, 1.4% came from nursing homes (NH), and 55.5% were self-referred (SR). The SR group had a higher adjusted odds ratio (aOR) for non-urgent conditions (1.98 CI 1.85-2.12), but a lower aOR for conditions amenable to ambulatory care (0.53 CI 0.48-0.59), and a lower consumption of resources. The SR group tend to occur more frequently out of hours, and to coincide with a shorter stay at the ED, lower observation unit activation rates, lower hospitalization rates and a lower consumption of services than other two groups. The average costs for all procedures were lower for the SR patients (mean = 106.04 € ± SD 84.90 €) than for those referred by PCPs (mean = 138.14 € ± SD 101.17 €) or NH (mean = 143.48 € ± SD 95.28 €). CONCLUSION Elderly patients coming in ED have different characteristics, outcomes and recourses consume by referral pattern.