Cardiovascular diseases are the main cause of death globally. From a pathological perspective, the causes of sudden cardiac death (SCD) are different in young individuals compared with older ones where chronic degenerative diseases predominate. Most patients with heart disease are elderly, but aging is not synonymous of disease. Many people live past the age of 65 up to 90 and over without evidence of cardiac diseases and in many autopsies of elderly individuals, no specific lesions can be discovered that provide a clear cause of cardiac death. Where age-related changes are observed and no other cardiovascular findings can be related to an arrhythmic or mechanical mechanism of SCD or to myocardial infarction (MI), the senile myocardial degeneration is an inappropriate diagnosis although it is a common expression used by public health physicians and pathologists as cause of death. Age-associated changes in senile myocardium predispose to pathophysiological disease mechanisms and they can be a substantial substrate causing SCD even after acute emotional or physical stress as triggers of myocardial ischemia or arrhythmia. However, distinguishing the age-related physiological processes from the associated pathological changes and their role in a case of SCD is not always possible, since a heart failure (HF) can be the final cardiovascular aging pathway especially in elderly victims. Furthermore, unnatural deaths can be erroneously reported as natural deaths, leaving accidents or homicides undetected. The differentiation between sudden death and fatal elderly abuse is a difficult and critical diagnostic decision that needs a careful post-mortem investigation also in SCDs. To the best of our knowledge, there is no protocol for distinguishing SCD from elderly abuse fatalities. A specific protocol for sudden deaths also in elderly (similar to those already available for infant and child) could enhance the public and professional awareness on elder abuse fatalities as well as on the underlying mechanisms of cardiac deaths. In cases of sudden, unexpected deaths in healthy elderly, it is strongly suggested an accurate post-mortem investigation including a complete examination of clinical signs and medical history, toxicological and/or chemical laboratory tests, circumstantial data related also to the scene-of-the event.