The first presentation of elderly people in the emergency department (ED) is commonly nonspecific and atypical, often in the form of geriatric syndromes, i.e. falls, immobility, incontinence, or deteriorating mental function. The purpose of this study was to evaluate the management and outcomes of institutionalized elderly people who initially presented with geriatric syndrome (GS) in the ED. A retrospective chart review of Banciao Veterans Care Home residents who visited the ED of a tertiary medical center was done. Demographic data including age, sex, modes of arrival, category of triage, time of visit, main presenting symptoms, principal diagnosis, medical expenditures, and clinical outcomes were recorded. From January to December, 2006, 629 ED visits (mean age, 82.1+/-5.3 years, all male) were retrieved. The overall prevalence of GS was 23.8%. When GS subjects were admitted, they were more likely to be transferred to step-down community hospitals for post-acute care (OR = 2.63; 95% CI: 1.36-5.08, p = 0.004). GS was common in institutionalized elderly people calling for ED services, and GS subjects were more likely to be transferred to step-down community hospitals after hospitalization. Comprehensive geriatric assessments may be of value for institutionalized elderly patients visiting the ED.