Delirium is prevalent among elderly people presenting to an emergency department (ED). However, despite the fact that delirium is associated with longer hospital stays, an increased rate of institutionalization and higher mortality (especially in the case of undiagnosed delirium), this condition often goes undiagnosed by ED doctors. We examined the rate of mental status assessment and the prevalence of delirium in the ED among patients older than 65 years in a large teaching hospital in Southern Israel via a retrospective chart review. Surprisingly we found no diagnosis of delirium in the medical charts of representative sample of 319 elderly people. Furthermore, only 12.5% of people received either an adequate or even a partially adequate mental status assessment by the ED doctors. We attribute these negative findings not to a low incidence of delirium but probably to a combination of a heavy workload along with a lack of adequate training of ED physicians. We suggest that part of the solution involves providing appropriate education to ED physicians as well as adding a geriatric consultant to the ED roster.