Movement Disorders

Vol. 21, No. 6, 2006, pp. 800 – 808

© 2006 Movement Disorder Society

Parkinsonism and Parkinson’s Disease in the Elderly: A

Community-Based Survey in Brazil (the Bambuı́ Study)

Maira Tonidandel Barbosa, MD, PhD,1 Paulo Caramelli, MD, PhD,1 Débora Palma Maia, MD,2
Mauro César Quintão Cunningham, MD,2 Henrique Leonardo Guerra, MD, PhD,3
Maria Fernanda Lima-Costa, MD, PhD,2,3 and Francisco Cardoso, MD, PhD2*
1
São Paulo University School of Medicine, São Paulo, Brazil
2
Federal University of Minas Gerais Medical School, Belo Horizonte, Brazil
3
Oswaldo Cruz Foundation René Rachou Research Center, Belo Horizonte, Brazil

Abstract: Several community-based surveys on the prevalence
of Parkinsonism and Parkinson’s disease have been conducted
worldwide, with variations on their methodology and results.
The objective of this study is to assess the prevalence of
Parkinsonism and its causes in a cohort of individuals age 64
years or older in Bambuı́, a Brazilian town. In phase I, 1,186
people older than 64 years responded to a 9-question screening
questionnaire for Parkinsonism. In phase II, all subjects who
scored ⱖ 2 points on the test were examined independently by
at least 2 movement disorder-trained physicians. A movement
disorder senior specialist excluded or confirmed the diagnosis
in all suspected cases. The response rate was high for both
phases (96% for phase I and 94% for phase II). The prevalence
rate per 100 population over 64 years of age in this group was
7.2% for Parkinsonism of all types (n ⫽ 86). The most frequent
causes were idiopathic Parkinson’s disease and drug-induced
Parkinsonism, with prevalence rates of 3.3% (n ⫽ 39) and 2.7%
(n ⫽ 32), respectively. The prevalence of vascular Parkinson-
ism was 1.1% (n ⫽ 13). We found 1 case of posttraumatic
Parkinsonism and another with multiple system atrophy. In this
first population-based study of Parkinsonism conducted in Bra-
zil, the prevalence in a cohort of elderly subjects was higher
than the observed in other populations worldwide, especially
because of the high rates of drug-induced and vascular Parkin-
sonism. The prevalence of Parkinson’s disease was similar to
that observed in elderly people in door-to-door surveys in other
American, European, and Eastern countries. © 2006 Movement
Disorder Society
Key words: epidemiology; Parkinsonism; Parkinson’s dis-
ease; drug-induced Parkinsonism; vascular Parkinsonism

Parkinsonism is one of the most prevalent chronic
neurological syndromes in the elderly, and it constitutes
the second most frequent type of movement disorders in
this group, after essential tremor.1,2 Over the past 2
decades, several investigations of the prevalence of Par-
kinsonism, Parkinson’s disease (PD), and their specific
age distributions among different populations have been
carried out.3–7
PD is usually the most commonly identified cause of
Parkinsonism, with prevalence estimates reported from
*Correspondence to: Dr. Francisco Cardoso, Neurology Service–
UFMG, Av Pasteur 89/1107, 30150-290 Belo Horizonte, MG, Brazil.
E-mail: cardosofe@terra.com.br
Received 23 May 2005; Revised 23 August 2005; Accepted 9
September 2005
Published online 15 February 2006 in Wiley InterScience (www.
interscience.wiley.com). DOI: 10.1002/mds.20806
various studies and different populations ranging from
50 to 260 cases per 100,000 persons in the general
population. The prevalence of PD in the population over
60 years of age has been reported as approximately
1.6%, with little variation between different European
countries,7–13 and more variable in other American and
Eastern countries.14 –18 It increases sharply with age, and
most surveys show a slight male preponderance.6 Com-
parison of the results of prevalence surveys carried out to
date is difficult, owing to methodological differences in
case-finding, diagnostic criteria and accuracy, the geo-
graphical location, and the age-distribution of popula-
tions.6,7,19 –21 There may be ethnic variations, the preva-
lence being lower in Blacks, Japanese, and Asians.18,22–30
The previously observed differences in prevalence rates
could be the result of genetic and environmental factors,
as well as of ethnic-based differences, which have been
widely investigated. The ethnic differences in the genetic

800
 PARKINSONISM AND PD IN THE ELDERLY: THE BAMBUÍ STUDY
polymorphisms associated with PD may contribute to a
true difference in prevalence rates.18 However, several
community-based surveys on PD that have been per-
formed in recent years show that prevalence estimates
are probably less likely to vary across countries and
different geographical locations if similar methodology
and diagnostic criteria are used.7,21,26,31–34
The prevalence of Parkinsonism and PD in the com-
munity has never been studied in Brazil, and to our
knowledge, there are only five published surveys on this
topic in Latin America (Uruguay, Argentina, Cuba, Bo-
livia, and Colombia).35–37 The aim of the present inves-
tigation was to assess the prevalence of Parkinsonism
and PD in a cohort of elderly individuals in the town of
Bambuı́, Brazil, using a two-phase population-based ap-
proach. We also investigated the frequency and distribu-
tion of the other types of Parkinsonism and the newly
diagnosed patients with this syndrome.
POPULATION AND METHODS
Study Area and Population
This study was carried out in Bambuı́ (15,000 inhab-
itants), state of Minas Gerais, southeast Brazil. The illit-
eracy rate of this town is 11%, the Human Development
Index (HDI) is 0.700, and life expectancy is 70 years.38
The HDI, a summary composite index created by the
United Nations, measures a country’s average achieve-
ments in three basic aspects of human development:
longevity, knowledge, and a decent standard of living.
Longevity is measured by life expectancy at birth;
knowledge is measured by a combination of the adult
literacy rate and the combined primary, secondary, and
tertiary gross enrollment ratio; and standard of living by
gross domestic product per capita (purchasing power
parity, $US). For comparison, the HDI of the United
States is 0.939, whereas the index for Brazil is 0.775
(United Nations Development Program, Human Devel-
opment Reports; see online resource at http://hdr.
undp.org/statistics/faq/#21). Of note, Bambuı́ was an
endemic area for Chagas’ disease, although the transmis-
sion of Trypanosoma cruzi was eliminated in the 1970s.
However, mortality from Chagas’ disease remains high
among older inhabitants due to cohort effect.38,39 The
present investigation is part of the Bambuı́ Health and
Ageing Study (BHAS), a population-based cohort study,
designed to identify predictors of adverse health events
in the elderly.38 Bambuı́ is particularly suitable for such
a study, because its population has a low rate of migra-
tion and it shares demographic features with 60% of
Brazilian municipalities (Ministerio do Planejamento,
Orçamento e Gestão; see online resource http://www.
801
FIG. 1. Flow of the study with a screening questionnaire (phase I) and
a neurologic examination (phase II).
ibge.gov.br/). A complete census was carried out in 1996
for identification of cohort participants. All residents in
Bambuı́ 60 years of age or more on 1 January 1997 (n ⫽
1,742) were selected for the cohort study, and 1,606
participated. The prevalence of Parkinsonism was inves-
tigated in 2001, during the fourth follow-up, among the
survivors of the initial study population (n ⫽ 1,238).
From these, 1,186 (95.8%) responded to the screening
questionnaire. Of the 1,186 investigated inhabitants, 451
(38%) were men and 735 (62%) were women, with mean
age of 73.5 ⫾ 6.9 years, ranging from 64 to 98 years. The
age and sex distribution of this cohort is as follows: 64 to
69 years, 473 (40%); 70 to 74 years, 312 (26%), 75 to 79
years, 214 (18%); 80 to 84 years, 117 (10%); and ⱖ 85
years, 70 (6%). The female predominance is consistent
with the Brazilian population at this age and is the result
of the increased life expectancy of women in Brazil.
The project was approved by the Ethical Committee of
the Fundação Oswaldo Cruz (Fiocruz), and all partici-
pants provided written informed consent.
General Study Design
We used a two-phase case ascertainment approach to
reduce time and costs of the survey (Fig. 1). During
phase I, we administered a brief screening question-
naire40 (Table 1) to all subjects of the cohort and exam-
ined a sample of negative and positive individuals (0 –9
points on the questionnaire); in phase II, we confirmed or
excluded the presence of Parkinsonism in those subjects
who screened positively in the first phase.
Movement Disorders, Vol. 21, No. 6, 2006
802
TABLE 1. Screening questionnaire
Item no. A. English version (Tanner et al., 1990)42
1 Do you have trouble arising from a chair?
2 Is your handwriting smaller than it once
was?
3 Has anyone told you that your voice is
softer than it once was?
4 Is your balance, when walking, poor?
5 Do your feet suddenly seem to get stuck to
the floor?
6 Does your face seem less expressive than
it used to?
7 Do your arms or legs shake?
8 Do you have trouble buttoning buttons?
9 Do you shuffle your feet and take tiny
steps when you walk?
Phase I: Screening instrument.
In the first phase, trained interviewers visited all sub-
jects in their residence and applied the questionnaire
designed by Tanner and colleagues,40 which has been
used in several surveys of PD.12,41,42 This questionnaire
was translated into Spanish by Duarte and associates43
and showed a high sensitivity and specificity in the
population studied by these authors. It was chosen be-
cause of its brevity (9 objective questions) and the sim-
ilarity between the languages Spanish and Portuguese.
The questionnaire was adapted to Portuguese and tested
on patients with and without movement disorders at the
Neurology Outpatient Unit of the Hospital das Clı́nicas
of the Federal University of Minas Gerais, Brazil. The
Portuguese version of the questionnaire was well under-
stood and very easy to apply, even on subjects with little
education. The English and Portuguese versions of the
questionnaire are shown in the Appendix.
Subjects who responded positively to at least 2 of the
9 questions (n ⫽ 709) were selected for the second
phase. To evaluate whether the questionnaire yielded
false-negative cases, we examined 197 people randomly
selected among those who scored zero or one point
(41.3% of the negative), and none was found to have
Parkinsonism. We also asked about medications they
were taking, including a direct question about levodopa,
dopamine agonists, other antiparkinsonian drugs and do-
pamine-receptor blocking agents.
Phase II—Clinical Diagnosis.
Subjects who screened positive in phase I (at least 2
points on the questionnaire or 1 point plus use of those
drugs mentioned above) underwent a complete neurolog-
ical evaluation at the Public Health Unit or at home, if
they were unable to go to the clinic. This screening
criterion was based on the finding, described in the
Movement Disorders, Vol. 21, No. 6, 2006
M. T. BARBOSA ET AL.
Response B. Portuguese version Response
Yes/No O (a) senhor (a) tem dificuldade para se levantar de Sim/Não
uma cadeira?
Yes/No O (a) senhor (a) tem notado se a letra (a “escrita”) Sim/Não
ficou pequena, se reduziu o tamanho?
Yes/No Tem notado ou alguém comentou se a sua voz está Sim/Não
mais baixa ou mais fraca que era antes?
Yes/No Tem tido alterações do equilı́brio ao caminhar? Sim/Não
Yes/No Tem notado se os pés ficam presos ou agarrados no Sim/Não
chão ao atravessar portas?
Yes/No O (a) senhor (a) acha o seu rosto mais “parado,” menos Sim/Não
expressivo que era antes?
Yes/No Tem tremores nos braços ou nas pernas? Sim/Não
Yes/No Tem dificuldade para abotoar as roupas? Sim/Não
Yes/No O (a) senhor (a) arrasta os pés ou dá passos curtos ao Sim/Não
caminhar?
previous section, that score 0 or 1 had a false-negative
rate of 0. The sensitivity and specificity of score 2 or
greater were, respectively, 100% and 29%. Patients were
examined independently by at least 2 of 4 movement
disorder-trained neurologists or geriatrician (P.C.,
D.P.M., M.C.C., M.T.B.). A senior neurologist expert on
movement disorders (F.C.) evaluated each of the sus-
pected cases to make the diagnosis and etiologic classi-
fication of Parkinsonism.
A structured clinical work-up, comprising a standard-
ized history taking, complete neurological assessment,
and use of the Unified Parkinson’s Disease Rating Scale
(UPDRS) was used to diagnosis, classify, and quantify
Parkinsonism.44 A total number of 864 subjects (72.8%
of the total study population) were examined clinically,
including the random sample that screened negative
(zero or one point on the questionnaire) in phase I (n ⫽
197), and the positive cases (two and more points on the
screening questionnaire) were examined in phase II (n ⫽
667). It must be emphasized that 42 of the 709 subjects
who screened positive in phase I were not examined in
phase II due to refusal to participate in the study and
death.
Diagnostic Criteria
We defined Parkinsonism according to the Parkinson’s
Disease Society Brain Research Centre of the United
Kingdom criteria,5,45 requiring the presence of bradyki-
nesia and at least one of the following: rest tremor,
rigidity, or postural instability not caused by primary
visual, vestibular, cerebellar, or proprioceptive dysfunc-
tion. In each case, an attempt was made to classify the
cause of Parkinsonism according to the currently ac-
cepted clinical diagnostic criteria, which are outlined
below:
 PARKINSONISM AND PD IN THE ELDERLY: THE BAMBUÍ STUDY 803

Corticobasal degeneration.
NINDS-SPSP criteria.54

Dementia with Lewy bodies.

Consensus guidelines.55

Data Analysis
Prevalence rates were obtained for all types of Parkin-
sonism and for the specific etiologies, according with age
and gender. The 95% confidence intervals were calcu-
lated as described by Gardner and Altman.56 Data anal-
ysis was performed using the Stata v. 7.0 software pack-
age (Stata Statistical Software; Stata Corporation, 2001,
College Station, TX).57 Specifically, sex differences
were evaluated by the t test of Student for proportions,
FIG. 2. Classification of Parkinsonism in the study cohort. whereas analysis of variance (ANOVA) for proportions
was used to assess relationships between prevalence and
age. In both cases, significance level was set at 5%.
PD.
RESULTS
A diagnosis of idiopathic PD was established accord-
ing to the United Kingdom Brain Bank Criteria (UKBB – The number of confirmed cases of Parkinsonism of all
Parkinson’s Disease Society).45– 47 The other following types was 86 (Fig. 2), yielding a crude prevalence rate of
causes should have been excluded: 7.2 (95% confidence intervals [CI], 5.6 – 8.8) per 100
population for this group. Among them, 33 patients were
Drug-Induced Parkinsonism. male and 53 were female, with very similar prevalence
Drug-induced parkinsonism (DIP) was diagnosed if rates of 7.3% (95% CI, 5.7– 8.9) and 7.2% (95% CI, 5.6 –
there was history of use of antidopaminergic drugs in the 8.8; P ⫽ 0.94; Table 2). We diagnosed PD in 39 subjects,
6 months preceding the onset of symptoms, along with a yielding a prevalence of 3.3 (95% CI, 2.2– 4.4) per 100
previously negative history for the parkinsonian signs. If population. Seventeen of these patients were male and 22
possible, patients meeting these criteria were asked to were female, with prevalence rates of 3.8% (95% CI,
discontinue the offending drug and were examined 1 2.6 –5.0) and 3.0% (95% CI, 1.9 – 4.0). There was no
year later. The diagnosis was confirmed if the Parkin- statistically significant difference for PD prevalence be-
sonism disappeared on the second examination.48 tween men and women (P ⫽ 0.45; Table 2).
We found a high proportion of DIP: 32 subjects, 23
Vascular Parkinsonism. women and 9 men, accounting for a prevalence rate of
Vascular parkinsonism (VP) was defined by the pres-
ence of at least two of the following findings: history of TABLE 2. Age- and sex-specific prevalence rates of
repeated strokes with abrupt onset and stepwise progres- Parkinsonism and Parkinson’s disease in the study cohort
sion of Parkinsonism features, hypertension, broad-based
Age group (yr) Women, n (%) Men, n (%) Total, n (%)
rigid gait, and widespread pyramidal signs. The comput-
erized tomography (CT) or the magnetic resonance im- Parkinsonism
64-69 12 (4.2) 5 (2.7) 17 (3.6)
aging (MRI) showed vascular lesions in white matter, in 70-74 8 (4.1) 6 (5.2) 14 (4.5)
basal ganglia or widespread and bilateral in the cerebral 75-79 13 (9.8) 7 (8.6) 20 (9.3)
hemispheres.49 –51 80-84 12 (16) 7 (16.6) 19 (16.2)
ⱖ85 8 (18.6) 8 (29.6) 16 (22.8)
Total 53 (7.2) 33 (7.3) 86 (7.2)
Multiple System Atrophy. Parkinson’s
Criteria based on the Consensus Statement.52 disease
64-69 1 (0.3) 3 (1.6) 4 (0.8)
Progressive Supranuclear Palsy. 70-74 5 (2.5) 4 (3.5) 9 (2.9)
75-79 4 (3.0) 2 (2.5) 6 (2.8)
National Institute of Neurological Disorders and 80-84 7 (9.3) 3 (7.1) 10 (8.5)
Stroke and the Society for Progressive Supranuclear ⱖ85 5 (11.6) 5 (18.5) 10 (14.3)
Total 22 (3.0) 17 (3.8) 39 (3.3)
Palsy (NINDS-SPSP) criteria.53

Movement Disorders, Vol. 21, No. 6, 2006

804 M. T. BARBOSA ET AL.
TABLE 3. Age- and sex-specific prevalence rates of drug-
induced Parkinsonism in the Bambuı́ cohort
Age group (yr) Women, n (%) Men, n (%) Total, n (%)
64-69 9 (3.1) 1 (0.5) 10 (2.1)
70-74 1 (0.5) 2 (1.7)
75-79 6 (4.5) 2 (2.5)
80-84 5 (6.7) 2 (4.8)
ⱖ85 2 (4.7) 2 (7.4)
Total 23 (3.1) 9 (2.0) 32 (2.7)
2.7 (95% CI, 1.7–3.7) per 100 population (37.2% of all
patients with Parkinsonism) in this group (Table 3). It
must be emphasized that this figure reflects the result of
the follow-up evaluation, performed 1 year after the
initial examination. On that occasion, there were 37
patients with onset of Parkinsonism after exposure to
antidopaminergic drugs. Of note, for reasons beyond the
control of the authors, 9 of the 32 patients with the
diagnosis of DIP remained in use of the offending agents.
This was the second most common cause of parkinsonian
syndrome in this cohort, after PD, with a prevalence rate
also similar between men and women (2.0% and 3.1%,
respectively, P ⫽ 0.22) and increased with advanced age,
from 2.1% in the group 64 – 69 years old up to 5.7% in
the group ⱖ85 years old (P ⫽ 0.01; Table 3). The most
common dopamine-receptor blocking agents associated
with DIP were the calcium channel antagonists flunariz-
ine (7 cases) and cinnarizine (6 cases), or both in com-
bination (n ⫽ 2), corresponding to 47% of all cases.
These were followed by 12 cases (37.5%) receiving
conventional neuroleptic drugs (4 haloperidol, 3 chlor-
promazine, 2 sulpiride, 1 thioridazine, 1 pericyazine, and
1 taking haloperidol plus levomepromazine). The other 5
patients were taking amiodarone (3 cases), reserpine (1),
and alpha-methyldopa (1).
VP was the third most-frequent etiology, diagnosed in
13 cases, with a prevalence rate of 1.1% (95% CI, 0.4 to
1.8), with no sex difference. There was an increase in the
prevalence for men with advanced age (P ⫽ 0.01) but not
for women (P ⫽ 0.33). The other 2 patients were diag-
nosed as having posttraumatic Parkinsonism (a 74-year-
old woman who developed the symptoms after severe
head trauma) and multiple system atrophy (a 68-year-old
man; Fig. 2). All 13 patients diagnosed with VP had
pyramidal signs and at least one of the following: history
of repeated stroke, arterial hypertension, diabetes melli-
tus, Chagas’ disease with heart failure, or cardiac ar-
rhythmia. Six of the VP cases were confirmed by neu-
roimaging, and for each of them, the CT or MRI scan
revealed multiple infarcts in the basal ganglia. There
were no clinical differences between the patients with
diagnosis of VP with and without neuroimaging.
Movement Disorders, Vol. 21, No. 6, 2006
Prevalence figures of PS increased strongly with ad-
vancing age, from 3.6% in the group 64 – 69 years old to
9.3% in the age group 75–79 years and 22.8% in the age
group older than 85 years. This increase was statistically
3 (1.0) significant for men and women (P ⬍ 0.001 for both).
8 (3.7) Similarly, the prevalence of PD increased with advanc-
7 (6.0)
4 (5.7)
ing age, from 0.8% in the 64 – 69 year olds to 2.8% in the
75–79 year olds and 14.3% in the age group older than
85 years (P ⬍ 0.001). The frequency of DIP also in-
creased with advanced age, from 2.1% in the group
64 – 69 years old up to 5.7% in the group ⱖ 85 years old
(P ⫽ 0.01; Table 3).
Among the 86 patients with Parkinsonism, 52 (60.5%)
had not been diagnosed previously. Of the 39 identified
patients with PD, 28 (72%) had never been diagnosed
before the survey. These newly diagnosed PD patients
were referred for treatment and follow-up at the local
public health service. All 11 previously diagnosed PD
patients were treated with L-dopa and reported improve-
ment with this medication. The remaining 2 patients
were classified as having posttraumatic Parkinsonism
and multiple system atrophy.
Although the investigation of dementia was not among
the aims of the present study, this condition was found in
13 (15%) of the 86 patients with Parkinsonism: 5 patients
with VP and possible vascular dementia; 3 patients with
VP and probable Alzheimer’s disease and vascular de-
mentia; 3 patients with PD (possibly dementia related to
this illness); 1 case with DIP and probable Alzheimer’s
disease; 1 patient with PD and dementia associated with
head trauma.
DISCUSSION
The crude prevalence rate obtained in the present
study was 7.2% for all types of Parkinsonism and 3.3%
for PD. These rates were based on a total of 86 patients
with Parkinsonism, being 39 with PD and 47 with other
types of Parkinsonism, ascertained from a cohort of
1,186 elderly individuals. The prevalence of Parkinson-
ism is one of the highest already reported, especially
because of the high number of DIP (n ⫽ 32, 2.7%) and
VP (n ⫽ 13, 1.1%). In contrast, for instance, the EU-
ROPARKINSON study found a prevalence of 2.3%
among subjects 65 years of age or older in 5 European
countries.7 Similarly, in a study with methodology sim-
ilar to ours, Benito-León and colleagues found a preva-
lence of 2.2% for Parkinsonism of all types in three
elderly populations of Central Spain.13 On the other
hand, Bennett and associates found Parkinsonism in 34%
of 467 residents of East Boston who were 65 years of age
or older.61 It is possible that the discrepancy between the
results of this study and all other investigations, includ-
 PARKINSONISM AND PD IN THE ELDERLY: THE BAMBUÍ STUDY 805

TABLE 4. Prevalence of Parkinson’s disease in the elderly as reported in the literature

Parkinson’s Prevalence
Year, country Authors Population (n) Age (yr) disease (n) (%)
1989, China (Hong Kong) Ho et al.58 561 ⱖ60 19 3.4
1994, France (Gironde) Tison et al.8 3,149 ⬎65 60 1.4
1994, Canada (Saskatchewan) Moghal et al.59 70 ⱖ65 4 3.0
1995, Netherlands De Rijk et al.10 6,969 ⬎55 97 1.4
(Rotterdam)
1995, USA (Manhattan) Mayeux et al.22 1,941 ⱖ65 23 1.2
1995, Germany (Starnberg) Trenkwalder et al.9 982 ⬎65 7 0.7
1996, USA (Boston) Bennett et al.61 467 ⱖ65 15 3.2
1997, EUROPARKINSON De Rijk et al.7 14,636 ⬎65 320 1.6
1997, Argentina (Junin) Melcon et al.36 3,798 ⱖ60 48 1.3
2000, Europe De Rijk et al.11 18,506 ⱖ65 322 1.8
2000, China (Beijing) Chan et al.20 2,090 ⱖ55 29 1.4
2001, Sidney Chan et al.33 527 ⬎55 19 3.6
2002, Israel Anca et al.62 14,646 ⬎60 138 0.9
2002, Italy (South Tyrol) Kis et al.12 750 ⬎65 12 1.5
2003, Central Spain Benito-León et al.13 5,278 ⱖ65 81 1.5
2003, China (Beijing) Zhang et al.21 5,743 ⬎55 64 1.0

ing ours, can be accounted for by methodological
differences.
Despite some methodological differences, the overall
prevalence estimates for PD in this cohort are in agree-
ment with the results from recently published American,
European, and some Eastern community-based surveys
(Table 4). In the EUROPARKINSON cohort, PD was
diagnosed in 1.6% of the subjects,7 a figure virtually
identical to the result reported by the recent study in
Central Spain, 1.5%.13 Even in the survey of East Bos-
ton, the figure of 3.2% is not very different from the
prevalence of PD in Bambuı́.61 In an investigation in
Argentina, also using a two-phase methodology (screen-
ing with questionnaire followed by investigation), the
prevalence rate of PD among people 60 years of age or
older was 1.3%.36 Not surprisingly, studies performed in
settings other than the community reach different results.
Chan and coworkers, for instance, found PD in 4.9% of
203 residents of nursing homes in Australia.33 In our
survey, the overall prevalence of PD increased with age,
reaching a peak by the age group older than 84 years.
Four patients with PD were older than 90 years. Some
studies have reported an increase of PD prevalence with age
until the oldest group (above 85 or 90 years),4,7,8,10,33,36,63
whereas others have found a decline in prevalence
rates.11,13,60,64 This difference has been explained by po-
tential underdiagnosis of Parkinsonism in the oldest age
groups, because of the difficulty in differentiating par-
kinsonian signs in the elderly from associated morbidity
(e.g., peripheral neuropathy, arthrosis, depression).2,12
Another potential explanation for this controversy is the
instability of rates because in many of these investiga-
tions, very few cases at very high ages have been
found.13 In the present study, the overall prevalence of
Parkinsonism and PD were very similar in men and
women, which is in keeping with the results of oth-
ers,4,7,8,12,60 but different from other studies that have
found a male predominance.6,13,22,32,36,65 A recent inci-
dence study in 8 Italian municipalities showed that men
had twice the risk of developing PD compared with
women.66
In this survey, 28 (72%) of the identified PD patients
were de novo cases. Although lower figures have been
reported in other areas (12% in the Netherlands10 and
23.5% in Argentina36), results similar to ours have also
been described in both developing and developed coun-
tries such as 50% in Germany,9 69% in China,21 and 83%
in South Tyrol.12 Potential explanations for the latter
findings are (1) some patients have mild forms of the
disease in the early stages, making the diagnosis of PD
more challenging, particularly to non-movement disor-
ders specialists; (2) in many cases, affected subjects,
their families, and even their own general physicians
consider parkinsonian signs and symptoms as “normal”
ageing-related conditions; (3) restricted access to spe-
cialist medical services in many places, especially in
geographically remote areas. In any case, the conclusion
is that there is an elevated number of patients with
nondiagnosed PD in the community, making this an
important public health problem worldwide.
We detected 32 patients with DIP (37.2% of all cases
of Parkinsonism), with a high prevalence rate (2.7%).
The drugs most frequently associated with DIP in our
study were calcium-channel antagonists and conven-
tional neuroleptics. These findings confirm one previous
investigation by our group performed in a tertiary health

Movement Disorders, Vol. 21, No. 6, 2006

806 M. T. BARBOSA ET AL.
care center.67 The remarkable number of patients suffer-
ing from DIP is usually underestimated and constitutes
an important health problem not only in Brazil but also in
other countries where a high prevalence of this condition
has been reported. Other community-based surveys have
also found a high proportion of DIP: 23.5% of all sub-
jects with Parkinsonism in Germany9; 22% in Central
Spain13; 14.2% in Lower Aragon, Spain65; 11% in Ar-
gentina36; and 8.8% in Italy.4
There are wide variations in the estimates of the fre-
quency of VP worldwide. These discrepancies are
largely explained by variation in case definition.68,69
When studies are limited to those with either imaging or
pathological support for the diagnosis, 3% to 6% of all
cases of patients with Parkinsonism are found to have a
vascular etiology.51,68 We adopted previously published
diagnostic criteria of VP: predominant lower body in-
volvement, poor response to L-dopa therapy, multiple
ischemic lesions in brain imaging, and acute onset of
symptoms after a stroke.49,50 The high number of VP we
found (13 patients, accounting for 15.1% of all cases of
Parkinsonism and prevalence rate of 1.1%) can be related
to the well-established vascular risk factors such as ar-
terial hypertension, smoking and diabetes mellitus, and,
particularly, to the high prevalence of Chagas’ disease in
this cohort. In the first year of the BHAS study, it was
found that 37.7% of the study population presented T.
cruzi seropositivity.39 As it is well known, the latter is
associated with heart failure or cardiac arrhythmia and
symptomatic cerebrovascular disease, mainly ischemic
stroke.39,70 –72
Taking into account the data of the study of Schrag
and coworkers,73 which has reported one of the highest
prevalence of progressive supranuclear palsy and multi-
ple system atrophy (MSA), we would predict to find 0.12
and 0.09 cases of these two conditions in the 1,186
participants of our study. It must be emphasized that the
English study consisted of review of medical records, a
method that often yields higher frequency of rare and
unusual disorders due to selection bias, whereas our
investigation was community based. Thus, it is not sur-
prising that atypical Parkinsonism was virtually not en-
countered in the cohort assessed in this study.
In conclusion, the prevalence of Parkinsonism ob-
served in this cohort of elderly individuals was higher
than in many previously reported surveys, and this find-
ing was mainly related to the high number of DIP and VP
cases, because the prevalence of PD was similar to other
studies in elderly populations. Of note, 72% of the PD
patients detected in the study had not been diagnosed
previously. Atypical Parkinsonism occurred in only 1
patient, diagnosed with MSA.
Movement Disorders, Vol. 21, No. 6, 2006
Acknowledgments: We thank the BHAS project and coor-
dinator for supporting this project. We thank Dr. Josélia Firmo,
Mr. Paulo Acácio Lamounier, Marcelo, Nádia, and Maria Luzia
for local support. We thank the physicians working in Bambuı́,
who provide medical assistance and care for the parkinsonian
patients. This research was rendered possible because of the
wide acceptance of the elderly cohort of Bambuı́ and their
relatives in participating in all phases of the study.
REFERENCES
1. Louis ED, Marder K, Cote L, et al. Prevalence of a history of
shaking in persons 65 years of age and older: diagnostic and
functional correlates. Mov Disord 1996;11:63– 69.
2. Meara J, Koller WC. Parkinson’s disease and Parkinsonism in the
elderly. Cambridge: Cambridge University Press; 2000.
3. Pedro-Cuesta J. Parkinson’s disease occurrence in Europe. Acta
Neurol Scand 1991;84:357–365.
4. Morgante L, Rocca WA, Di Rosa AE, et al. Prevalence of Parkin-
son’s disease and other types of parkinsonism: a door-to-door
survey in three Sicilian municipalities. Neurology 1992;42:1901–
1907.
5. Quinn N. Parkinsonism—recognition and differential diagnosis.
BMJ 1995;310:447– 452.
6. Tanner CM, Ben-Shlomo Y. Epidemiology of Parkinson’s disease.
In: Stern GM, editor. Parkinson’s disease. Advances in neurology.
Philadelphia: Lippincott Williams and Wilkins; 1999. p 153–159.
7. de Rijk MC, Tzourio C, Breteler MMB, et al. Prevalence of
parkinsonism and Parkinson’s disease in Europe: the EUROPAR-
KINSON collaborative study. J Neurol Neurosurg Psychiatry
1997;62:10 –15.
8. Tison F, Dartigues JF, Dubes L, Zuber M, Alperovitch A, Henry P.
Prevalence of Parkinson’s disease in the elderly: a population study
in Gironde, France. Acta Neurol Scand 1994;90:111–115.
9. Trenkwalder C, Schwarz J, Gebhard J, et al. Starnberg trial on
epidemiology of Parkinsonism and hypertension in the elderly.
Arch Neurol 1995;52:1017–1022.
10. de Rijk MC, Breteler MMB, Graveland GA, et al. Prevalence of
Parkinson’s disease in the elderly: the Rotterdam Study. Neurology
1995;45:2143–2146.
11. de Rijk MC, Launer LJ, Berger K, et al. Prevalence of Parkinson’s
disease in Europe: a collaborative study of population-based co-
horts. Neurology 2000;54(Suppl. 5):S21–S23.
12. Kis B, Schrag A, Ben-Shlomo Y, et al. Novel three-stage ascer-
tainment method - prevalence of PD and parkinsonism in South
Tyrol, Italy. Neurology 2002;58:1820 –1825.
13. Benito-León J, Bermejo-Pareja F, Rodrı́guez J, Molina JA, Gabriel
R, Morales JM, for the Neurological Disorders in Central Spain
(NEDICES) Study Group. Prevalence of PD and other types of
Parkinsonism in three elderly populations of central Spain. Mov
Disord 2003;18:267–274.
14. Anderson DW, Schoenberg BS, Haerer AF. Racial differentials in
the prevalence of major neurological disorders. Background and
methods of the Copiah County study. Neuroepidemiology 1982;1:
17–30.
15. Zhang ZX, Román GC. Worldwide occurrence of Parkinson’s
disease: an update review. Neuroepidemiology 1993;12:195–208.
16. Nicoletti A, Sofia V, Bartoloni A, et al. Prevalence of Parkinson’s
disease: a door-to-door survey in rural Bolivia. Parkinsonism Relat
Disord 2003;10:19 –21.
17. Pradilla G, Vesga BE, León-Sarmiento FE y grupo GENECO.
Estudio neuroepidemiológico nacional (EPINEURO) colombiano.
Pan Am J Public Health 2003;14:104 –111.
18. Woo J, Lau E, Ziea E, Chan DKY. Prevalence of Parkinson’s
disease in a Chinese population. Acta Neurol Scand 2004;109:
228 –231.
 PARKINSONISM AND PD IN THE ELDERLY: THE BAMBUÍ STUDY
19. Chan DKY, Hung WT, Wong A, Hu E, Beran RG. Validating a
screening questionnaire for parkinsonism in Australia. J Neurol
Neurosurg Psychiatry 2000;69:117–120.
20. Chan P, Tanner CM, Zhao L, et al. Prevalence of Parkinson’s
disease in Beijing, China. Neurology 2000;54(Suppl. 3):A348.
21. Zhang ZX, Anderson DW, Huang JB, et al. Prevalence of Parkin-
son’s disease and related disorders in the elderly population of
Greater Beijing, China. Mov Disord 2003;18:764 –772.
22. Mayeux R, Marder K, Cote LJ, et al. The frequency of idiopathic
Parkinson’s disease by age, ethnic group, and sex in Northern
Manhattan, 1988 –1993. Am J Epidemiol 1995;142:820 – 827.
23. Schoenberg BS, Osuntokun BO, Adeuja AOG, et al. Comparison
of the prevalence of Parkinson’s disease in black populations in the
rural United States and in the rural Nigeria: door-to-door commu-
nity studies. Neurology 1988;38:645– 646.
24. Li SC, Schoenberg BS, Wang CC, et al. A prevalence survey of
Parkinson’s disease and other movement disorders in the People’s
Republic of China. Arch Neurol 1985;42:655– 657.
25. Tekle-Haimanot R, Abebe M, Gebre-Mariam A, Forsgren L, Hei-
jbel Holmgren G, Ekstedt J. Community-based study of neurolog-
ical disorders in rural central Ethiopia. Neuroepidemiology 1990;
9:263–277.
26. Wang SJ, Fuh JL, Teng EL, et al. A door-to-door survey of
Parkinson’s disease in a Chinese population in Kinmen. Arch
Neurol 1996;53:66 –71.
27. Wang SJ, Fuh JL, Liu CY, et al. Parkinson’s disease in Kin-Hu,
Kinmen: a community survey by neurologists. Neuroepidemiology
1994;13:69 –74.
28. Kusumi M, Nakashima K, Harada H, Nakayama H, Takahashi K.
Epidemiology of Parkinson’s disease in Yonago City, Japan: com-
parison with a study carried out 12 years ago. Neuroepidemiology
1996;15:201–207.
29. Saha SP, Bhattacharya S, Das SK, Maity B, Roy T, Raut DK.
Epidemiological study of neurological disorders in a rural popula-
tion of Eastern India. J Indian Med Assoc 2003;101:299 –304.
30. Tan LCS, Venketasubramanian N, Hong CY, et al. Prevalence of
Parkinson’s disease in Singapore. Neurology 2004;62:1999 –2004.
31. Liou HH, Chang SF, Su CL, et al. Prevalence of Parkinson’
disease: a door-to-door survey in Illan, Taiwan. Neurology 2000;
54(Suppl. 3):A347.
32. Schrag A, Ben-Shlomo Y, Quinn NP. Cross sectional prevalence
survey of idiopathic Parkinson’s disease and parkinsonism in Lon-
don. BMJ 2000;321:21–22.
33. Chan DKY, Dunne M, Wong A, Hu E, Hung WT, Beran RG. Pilot
study of prevalence of Parkinson’s disease in Australia. Neuroepi-
demiology 2001;20:112–117.
34. Taba P, Asser T. Prevalence of Parkinson’s disease in Estonia.
Acta Neurol Scand 2002;106:276 –281.
35. Ketzoian C, Rega I, Caseres R, et al. Estudio de prevalencia de las
principales enfermedades neurologicas en una población del Uru-
guay. La Prensa Medica Uruguaya 1997;17:9 –26.
36. Melcon MO, Anderson DW, Vergara RH, Rocca WA. Prevalence
of Parkinson’s disease in Junı́n, Buenos Aires Province, Argentina.
Mov Disord 1997;12:197–205.
37. Giroud Benı́tez JL, Collado-Mesa F, Esteban EM. Prevalencia de
la enfermedad de Parkinson en un área urbana de la provincia
Ciudad de la Habana, Cuba. Estudio poblacional “puerta a puerta.”
Neurologı́a 2000;15:269 –273.
38. Lima e Costa MFF, Uchoa E, Guerra H, Firmo JOA, Vidigal PG,
Barreto SM. The Bambuı́ Health and Ageing Study (BHAS):
methodological approach and preliminary results of a population-
based cohort study of the elderly in Brazil. Rev Saúde Pública
2000;34:126 –135.
39. Lima e Costa MFF, Barreto SM, Guerra HL, Firmo JOA, Uchoa E,
Vidigal PG. Ageing with Trypanosoma cruzi infection in a com-
munity where the transmission has been interrupted: the Bambuı́
Health and Ageing Study (BHAS). Int J Epidemiol 2001;30:887–
893.
807
40. Tanner CM, Gilley DW, Goetz CG. A brief screening question-
naire for Parkinsonism. Ann Neurol 1990;28:267–268.
41. Rocca WA, Maraganore DM, McDonell SK, Schaid DJ. Validation
of a telephone questionnaire for Parkinson’s disease. J Epidemiol
1998;51:517–523.
42. Pramstaller PP, Falk M, Schoenhuber R, Poewe W. Validation of
a mail questionnaire for parkinsonism in two languages (German
and Italian). J Neurol 1999;246:79 – 86.
43. Duarte J, Claverı́a LE, Pedro-Cuesta J, Sempere AP, Coria F,
Calne DB. Screening Parkinson’s disease: a validated question-
naire of high specificity and sensitivity. Mov Disord 1995;10:643–
649.
44. Fahn S, Elton RL, Members of the UPDRS Development Com-
mittee Unified Parkinson’s disease rating scale. In: Fahn S, Mars-
den CD, Calne DB, editors. Recent developments in Parkinson’s
disease. Vol. 2. Florham Park, NJ: MacMillan Healthcare infor-
mation; 1987. p 153–163.
45. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical
diagnosis of idiopathic Parkinson’s disease: a clinico-pathological
study of 100 cases. J Neurol Neurosurg Psychiatry 1992;55:181–
184.
46. Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features
improve the accuracy of clinical diagnosis in Parkinson’s disease:
a clinicopathologic study. Neurology 1992;42:1142–1146.
47. Hughes AJ, Daniel SE, Lees AJ. Improved accuracy of clinical
diagnosis of Lewy body Parkinson’s disease. Neurology 2001;57:
1497–1499.
48. Jiménez-Jiménez FJ, Ortı́-Pareja M, Ayuso-Peralta L, et al. Drug-
induced parkinsonism in a movement disorders unit: a four-year
survey. Parkinsonism Relat Disord 1996;2:145–149.
49. Jankovic J. Lower body (vascular) parkinsonism. Arch Neurol
1990;47:728.
50. Winitakes J, Jankovic J. Clinical correlates of vascular parkinson-
ism. Arch Neurol 1999;56:98 –102.
51. Foltynie T, Barker R, Brayne C. Vascular Parkinsonism: a review
of the precision and frequency of the diagnosis. Neuroepidemiol-
ogy 2002;21:1–7.
52. Gilman S, Low PA, Quinn N, et al. Consensus statement on the
diagnosis of multiple system atrophy. J Neurol Sci 1999;163:94 –
98.
53. Litvan I, Agid Y, Jankovic J, et al. Accuracy of clinical criteria for
the diagnosis of progressive supranuclear palsy (Steele-Richard-
son-Olszewski syndrome). Neurology 1996;46:922–930.
54. Litvan I, Agid Y, Goetz C, et al. Accuracy of the clinical diagnosis
of corticobasal degeneration: a clinicopathologic study. Neurology
1997;48:119 –125.
55. McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for
the clinical and pathological diagnosis of dementia with Lewy
bodies (DLB): report of the consortium on DLB international
workshop. Neurology 1996;47:1113–1124.
56. Gardner MJ, Altman DG. Confidence intervals rather than P val-
ues: estimation rather than hypothesis testing. BMJ 1986;292:746 –
750.
57. Stata Statistical Software (computer program). Release 7.0. Col-
lege Stations, TX: Stata Corporation; 2001.
58. Ho SC, Woo J, Lee CM. Epidemiologic study of Parkinson’s
disease in Hong Kong. Neurology 1989;39:1314 –1318.
59. Moghal S, Rajput AH, D’Arcy C, Rajput R. Prevalence of move-
ment disorders in elderly community residents. Neuroepidemiol-
ogy 1994;13:175–178.
60. Schoenberg BS, Anderson DW, Haerer AF. Prevalence of Parkin-
son’s disease in the biracial population of Copiah County, Missis-
sippi. Neurology 1985;35:841– 845.
61. Bennett DA, Beckett LA, Murray AM, et al. Prevalence of par-
kinsonism signs and associated mortality in a community popula-
tion of older people. N Engl J Med 1996;334:71–76.
62. Anca M, Paleacu D, Shabtai H, Giladi N. Cross-sectional study of
the prevalence of Parkinson’s disease in the Kibbutz movement in
Israel. Neuroepidemiology 2002;21:50 –55.
Movement Disorders, Vol. 21, No. 6, 2006
808 M. T. BARBOSA ET AL.
63. Bharucha NE, Bharucha EP, Bharucha AE, Bhise AV, Schoenberg
BS. Prevalence of Parkinson’s disease in the Parsi community of
Bombay, India. Arch Neurol 1988;45:1321–1323.
64. Sutcliffe RLG, Meara JR. Parkinson’s disease epidemiology in the
Northampton District, England, 1992. Acta Neurol Scand 1995;
92:443– 450.
65. Errea-Abad JM, Ara-Callizo JR, Aibar-Remón C, Pedro-Cuesta J.
Prevalence of Parkinson’s disease in Lower Aragon, Spain. Mov
Disord 1999;14:596 – 604.
66. Baldereschi M, DiCarlo A, Vanni P, et al. and the Italian longitu-
dinal study on aging working group. Life-style related risk factors
for Parkinson’s disease: a population study. Acta Neurol Scand
2003;108:239 –244.
67. Cardoso F, Camargos ST, Silva GA Jr. Etiology of parkinsonism in
a Brazilian movement disorders clinic. Arq Neuropsiquiatr 1998;
56:171–175.
Movement Disorders, Vol. 21, No. 6, 2006
68. Sibon I, Tison F. Vascular parkinsonism. Curr Opin Neurol 2004;
17:49 –54.
69. Papapetropoulos S, Ellul J, Argyriou AA, Chroni E, Papapetro-
poulos T. The effect of vascular disease on late onset Parkinson’s
disease. Eur J Neurol 2004;11:231–235.
70. Carod-Artal FJ, Vargas AP, Melo M, Horan TA. American
trypanosomiasis (Chagas’ disease): an unrecognized cause of
stroke. J Neurol Neurosurg Psychiatry 2003;74:516 –518.
71. Leon-Sarmiento FE, Mendoza E, Torres-Hillera M, et al. Trypano-
soma cruzi-associated cerebrovascular disease: a case-control
study in Eastern Colombia. J Neurol Sci 2004;217:61– 64.
72. Pitella JEH. Ischemic cerebral changes in the chronic chagasic
cardiopathy. Arq Neuropsiquiatr 1984;42:105–115.
73. Schrag A, Ben-Shlomo Y, Quinn NP. Prevalence of progressive
supranuclear palsy and multiple system atrophy: a cross-sectional
study. Lancet 1999;354:1771–1775.