OBJECTIVES: High-risk patients >/=65 y of age with coronavirus disease 2019 (COVID-19) tended to have lower serum prealbumin concentrations. The aim of this study was to investigate the association of prealbumin at baseline on COVID-19-related mortality in elderly patients (>/=65 y of age). METHODS: We non-selectively and consecutively collected participants from Tongji Hospital in Wuhan from January 17 to February 17, 2020. Univariate and multivariate logistic regression models were employed to evaluate the correlation between prealbumin and in-hospital outcomes (in-hospital mortality, admission to the intensive care unit [ICU], and mechanical ventilation) in elderly patients with COVID-19. Linear trend was performed by entering the median value of each category of prealbumin tertile as a continuous variable and was visually confirmed by using generalized additive models. Interaction and stratified analyses were conducted as well. RESULTS: We included 446 elderly patients with COVID-19 in the final analyses. In-hospital mortality was 14.79%. Of the 446 patients, 15.47% were admitted to the ICU and 21.3% required mechanical ventilation. Compared with patients in the highest tertile, the prealbumin of patients in the lowest tertile had a 19.09-fold higher risk for death [odds ratio (OR), 20.09; 95% confidence interval (CI), 3.62-111.64; P = 0.0006], 25.39-fold higher risk for ICU admission (OR, 26.39; 95% CI, 4.04-172.39; P = 0.0006), and 1.8-fold higher risk for mechanical ventilation (OR, 2.8; 95% CI, 1.15-6.78; P = 0.0227) after adjustment for potential confounders. There was a linear trend correlation between serum prealbumin concentration and risk for in-hospital mortality, ICU admission, and mechanical ventilation in elderly patients with COVID-19 infection. CONCLUSION: Prealbumin is an independent risk factor of in-hospital mortality for elderly patients with COVID-19. Assessment of prealbumin may help identify high-risk individuals >/=65 y of age with COVID-19.