Clinical scores determining the likelihood of acute appendicitis (AA), including the Alvarado score, were devised using a younger population, and their efficacy in predicting AA in elderly patients is not well documented. This study's purpose is to evaluate the utility of Alvarado scores in this population. A retrospective chart review of patients >65 years old presenting with pathologically diagnosed AA from 2000 to 2010 was performed. Ninety-six patients met inclusion criteria. The average age was 73.7 ± 1.5 years and our cohort was 41.7 per cent male. The average Alvarado score was 6.9 ± 0.33. The distribution of scores was 1 to 4 in 3.7 per cent, 5 to 6 in 37.8 per cent, and 7 to 10 in 58.5 per cent of cases. There was a statistically significant increase in patients scoring 5 or 6 in our cohort versus the original Alvarado cohort (P < 0.01). Right lower quadrant tenderness (97.6%), left shift of neutrophils (91.5%), and leukocytosis (84.1%) were the most common symptoms on presentation. In conclusion, our data suggest that altering our interpretation of the Alvarado score to classify elderly patients presenting with a score of ≥5 as high risk may lead to earlier diagnosis of AA. Physicians should have a higher clinical suspicion of AA in elderly patients presenting with right lower quadrant tenderness, left shift, or leukocytosis.