Objective: To describe and compare characteristics of ambulance attendances for older adults with and without dementia Methods: A retrospective cohort study was conducted using electronic patient care records from the main ambulance service in Western Australia. All attendances for people aged 65 years or older in the years 2019-21 were included. Dementia status was adjudicated from the clinical history and medication lists. Patient and case characteristics of those with and without dementia were compared and stratified by type of residence. Results: There were 277,996 emergency ambulance attendances made by 124,711 older adults, of whom 23.5% had dementia. The mean number of attendances per person was 3.3 in the dementia cohort vs 2.0 in those without dementia. Falls were the leading reason for ambulance attendance. People with dementia were significantly frailer, required longer at-scene intervals, were less likely to be transported as the highest priority, and had lower 30-day survival. Conclusions: Dementia is common amongst older adults attended by paramedics and is associated with higher ambulance utilization per person. People with dementia attended by paramedics have stronger signals of vulnerability, such as increased frailty. As the number of people living with dementia increases in the future, there are implications for workforce training and service planning. There are opportunities for developing alternatives to emergency department transportation for some people with dementia.