Original Research Article

Dement Geriatr Cogn Disord 2008;26:291–299 Accepted: June 16, 2008

Published online: October 9, 2008
DOI: 10.1159/000161053

Estimate of Dementia Prevalence in

a Community Sample from São Paulo,
Brazil
Cássio M.C. Bottino a Dionisio Azevedo, Jr. a Mariana Tatsch a
Sergio R. Hototian a Marco A. Moscoso a Jefferson Folquitto a
Andreia Z. Scalco a Mario C. Bazzarella a Marcos A. Lopes a Julio Litvoc b
a
Old Age Research Group (PROTER), Institute and Department of Psychiatry, and
b
Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil

Key Words causes of dementia. Dementia prevalence in Brazil and in

Dementia prevalence ⴢ Alzheimer’s disease ⴢ Vascular
dementia ⴢ Risk factors
Abstract
Aims: To estimate dementia prevalence and describe the eti-
ology of dementia in a community sample from the city of
São Paulo, Brazil. Methods: A sample of subjects older than
60 years was screened for dementia in the first phase. During
the second phase, the diagnostic workup included a struc-
tured interview, physical and neurological examination, lab-
oratory exams, a brain scan, and DSM-IV criteria diagnosis.
Results: Mean age was 71.5 years (n = 1,563) and 58.3% had
up to 4 years of schooling (68.7% female). Dementia was di-
agnosed in 107 subjects with an observed prevalence of
6.8%. The estimate of dementia prevalence was 12.9%, con-
sidering design effect, nonresponse during the communi-
ty phase, and positive and negative predictive values. Alz-
heimer’s disease was the most frequent cause of dementia
(59.8%), followed by vascular dementia (15.9%). Older age
and illiteracy were significantly associated with dementia.
Conclusions: The estimate of dementia prevalence was
higher than previously reported in Brazil, with Alzheimer’s
disease and vascular dementia being the most frequent
other Latin American countries should be addressed by
additional studies to confirm these higher dementia rates
which might have a sizable impact on countries’ health
services. Copyright © 2008 S. Karger AG, Basel
Introduction
The gradual growth of the elderly population in devel-
oped countries such as the European countries and the
United States has been described during the last few
years. This increase in the number of elderly people has
also been noticed in less developed countries.
A study on the impact of the demographic transition
process in Latin American countries [1] has compared
1980–1985 with 2020–2025, and has found that while the
mortality (cases/1,000) and fertility rates will decrease
from 8.2 to 6.7, and from 32.3 to 21.6, respectively, life
expectancy will increase from 64.1 to 71.8 years, the
number of elderly people (160 years) will grow from 23.3
to 93.3 million, and the proportion of elderly individuals
will increase from 6.4 to 10.8% during this period of
time.

© 2008 S. Karger AG, Basel Dr. Cássio M.C. Bottino

1420–8008/08/0264–0291$24.50/0 Instituto de Psiquiatria do HC FMUSP
Fax +41 61 306 12 34 Rua Dr. Ovídio Pires de Campos, 785
E-Mail karger@karger.ch Accessible online at: São Paulo, SP 05403-010 (Brazil)
www.karger.com www.karger.com/dem E-Mail cbottino@usp.br
 In Brazil, a sharp and widespread fertility decline be-
gan by the end of the 1960s, with a consequent accelera-
tion of population aging, with deeper structural changes
than in developed countries for two reasons: the fertility
decline was faster, and it happened in a population with
a younger age structure [2]. Considering the results of the
Brazilian population census carried out in 1996, we no-
ticed that the percentage of 65-year-old or older Brazil-
ians increased from 4.01 to 5.37% of the general popula-
tion between 1980 and 1996. Those people older than 60
years, who used to represent 4.7% of the total population
in 1960, reached a rate of 6.1% in 1980, and jumped to
8.5% in 2000 [3].
In a recent consensus study on the global prevalence
of dementia, the authors [4] have estimated that 24.3 mil-
lion people currently have dementia, with 4.6 million
new cases per year (1 new case every 7 s). They have also
found that most demented people live in developing
countries (60% in 2001, a figure that will reach 71% in
2040). Therefore, we may suppose that direct and indirect
costs with the treatment of dementia cases in Brazil will
have a strong impact on the country during the next few
decades.
The objectives of the present study are to describe the
estimate of dementia prevalence in community-dwelling
elderly living in São Paulo, Brazil, to present the frequen-
cy of the causes of dementia, and to evaluate sociodemo-
graphic characteristics associated with this disease.
Methods
Study Design
A two-phase design was applied to estimate the prevalence of
dementia. In the first phase, subjects were screened for dementia,
and all the screen positives and a random sample of screen nega-
tives were invited to the second phase, or clinical evaluation.
Sample Selection
São Paulo is the biggest city in Brazil and according to the
‘Fundação Instituto Brasileiro de Geografia e Estatística’ in 2000
[3] the city’s population was 10,426,384 people, of whom 969,654
(9.3%) were 60 years old or older.
A cluster random sampling of a population of individuals aged
60 years and over from three different socioeconomic classes (up-
per, middle and low) was used. This strategy aimed to evaluate a
sample containing city districts that represent the universe of el-
derly living in São Paulo and had been used before in community
surveys with elderly in São Paulo [5] and Rio de Janeiro [6]. Ini-
tially, the 96 city districts were ranked from the wealthier to the
poorer according to data from the 2000 census, provided by the
Brazilian Institute of Geography and Statistics [3]. The following
parameters were applied: income, schooling, proportion of elder-
ly living in each district and sanitation. Afterwards, the districts
292 Dement Geriatr Cogn Disord 2008;26:291–299
were divided into three groups and one district representative of
each socioeconomic stratum was chosen to represent the upper,
middle and lower groups.
The parameters for sample size calculation were dementia
prevalence of 7%, a figure obtained from a previous dementia
prevalence study in Brazil [7], sampling accuracy or error (d) of
1.5, and 95% confidence interval. The population’s sample size
was calculated by Epi-Info 5.1 software, and resulted in a sample
of 1,650 individuals (1,980 considering 20% loss) to be inter-
viewed.
The 3 districts representing high, medium, and low socioeco-
nomic classes had 17,186, 17,738 and 14,443 elderly individuals,
respectively. In each of the 3 districts, 30 census sectors were se-
lected with a probability proportional to each cluster size. After-
wards, blocks of 10 domiciles were randomly chosen in each of the
90 selected census sectors. Following local media (newspaper, ra-
dio, television) and mail advertisement, a trained team started a
systematic door-knocking survey, visiting 8,042 domiciles to find
elderly subjects. After the identification, a sample of 2,233 sub-
jects older than 60 years was approached in the community, and
a total of 1,563 subjects who accepted to be visited by a trained
interviewer (response rate = 70%) was assessed. The interviewers
tried at least three times to evaluate the elderly subjects at home
before they were considered to be refusals. The reasons for non-
participation in the community phase were refusals (86%), un-
reachable (12%), and unable to answer the screening tests (2%).
The sociodemographic characteristics of the sample assessed
at home have recently been presented in greater detail [8]: mean
age was 71.4 years (range = 60–102; SD = 8.03), 83.5% with less
than 80 years of age, 68.7% were female, 16.6% were illiterate,
71.0% had up to 8 years of schooling, 73.6% were classified as
white and 15.6% as brown regarding skin color. According to the
2000 census [3], the city of São Paulo had 88.4% of elderly with
less than 80 years of age, 59.4% were female, 15.6% were illiterate,
80.0% had up to 8 years of schooling, 78.0% were classified as
white and 13.3% as brown according to skin color.
First Phase: Screening
The screening phase was described in greater detail elsewhere
[8], but briefly, a combination of cognitive tests and functional
scales were applied: the Mini Mental State Examination (MMSE)
[9] and the Fuld Object Memory Evaluation (FOME) [10] were
administered to the patients; the Informant Questionnaire on
Cognitive Decline in the Elderly (IQCODE) [11] and the Bayer-
Activities of Daily Living Scale (B-ADL) [12] were administered
to the informants. The following combination of tests had been
tested before in an independent sample, achieving high levels of
sensitivity and specificity for dementia screening [13]: MMSE
score ! 26 or FOME score !35 and IQCODE score 13.40 or B-
ADL score 13.19. However, for the present study, different MMSE
scores for each educational level [14] were used: (1) illiterate sub-
jects: ! 20; (2) 1–4 years of schooling: ! 25; (3) 5–8 years of school-
ing: ! 27, and (4) more than 9 years of schooling: ! 28. Those sub-
jects with scores below the cutoff points for one of the cognitive
tests and scores above the cutoff points for one of the functional
scales were considered to have cognitive and functional impair-
ment, or being screen positive for dementia.
The following instruments were also administered: sociode-
mographic questionnaire, and socioeconomic classification scale
(allowing 5 levels of classification). Data were collected at the do-
Bottino et al.
miciles between July 2002 and August 2003 and were obtained Table 1. Second (diagnostic) phase results
directly from the cognitively intact elderly subjects and/or from
an informant, who was usually a close relative, when the subject Total sample (n = 1,563)
was cognitively impaired.
The investigation was approved by the local ethics committee, screen positives for screen negatives for
dementia (n = 250) dementia (n = 1,313)
and all the subjects agreed to participate in the study by signing
the informed consent. n % n %

Second Phase: Diagnostic Evaluation Total selected 250 100.0 243 18.5
Screen positives for dementia were invited to participate in the Total invited 250 100.0 241 99.2
diagnostic evaluation performed by a physician of our group Evaluated 164 65.6 157 65.1
which consisted of 1 neurologist and 7 psychiatrists. The evalua- Deaths 18 7.2 9 3.7
tion included complete medical history, physical and neurological Refusals 12 4.8 29 12.0
examination, cranial computerized tomography or brain mag- Not found 56 22.4 46 19.1
netic resonance imaging, workup for the differential diagnosis of
dementia (complete blood count with differential; renal, liver and
thyroid function tests; vitamin B12 and folic acid levels; syphilis
serology; urinalysis), the application of the Cambridge Examina-
tion for Mental Disorders (CAMDEX) [15, 16] and a brief neuro-
psychological testing (CAMCOG – cognitive section of the CAM- screen negatives, and VP+ and VP– are the positive and the nega-
DEX). Part of the screen-positive subjects were interviewed at tive predictive values of the screening instrument.
home to reduce attrition, and only the clinical data (medical his- An additional weight was calculated to compare the sociode-
tory, physical and neurological evaluation) were collected for mographic factors associated with dementia considering the re-
those individuals. Diagnosis was made by consensus with at least sponse rate in the second phase of the study, which was multiplied
2 physicians, and the patients had to meet DSM-IV [17] criteria by the global weight. A comparison between the frequencies of the
for dementia and for dementia subtypes. categorical variables (bivariate analysis) was carried out using
Subjects were classified as ‘cognitively impaired not dement- Pearson’s or Rao-Scott ␹2. The comparison between the scores of
ed’ [18] if dementia was excluded but they presented cognitive continuous variables was performed using Student’s t test. The
impairment (not only memory) not caused by delirium, psychiat- possible associations between sociodemographic variables (age,
ric disorders and mental retardation. gender, schooling, skin color and social class) and the diagnosis
The screen-negative individuals (approximately 20%), who of dementia were analyzed using logistic regression.
were randomly selected considering the proportion of elderly
people in each educational level, were invited to go to the hospital
so that the CAMDEX (and the CAMCOG) could be adminis-
tered. Part of the screen negatives were interviewed at home to
reduce attrition. Results

Statistical Analysis The cognitive and functional impairment prevalence

Prevalence data were analyzed with SPSS software, version 14
for Windows, and the data weighted for cluster sampling and
nonresponse effects were analyzed with SAS software, version 9.1.
To address the nonresponse effect, a probability was calculated
dividing the number of elderly subjects interviewed in each sector
by the number of elderly subjects selected in each sector. The in-
verse of this probability was the weight to account for the nonre-
sponse effect. The global weight was calculated multiplying the
weight for the nonresponse by the weight for the cluster sam-
pling.
The estimate of dementia prevalence was measured based on
the standardized weight and the adjustment to the screening in-
strument performance, that is, adjusting the number of cases to
the positive and negative predictive values of the screening in-
strument, and considering the diagnosis made using CAMDEX
as the gold standard in the second phase of the study.
In order to calculate the estimate of prevalence, the following
formula was used [19]:
Pe = Ps (VP+) + Pn (1 – VP–)
where Pe is the prevalence estimate, Ps is equivalent to the propor-
tion of screen positives in the sample, Pn is the proportion of
observed in the 60-year-old subjects was 16% (n = 250;
95% CI 14.2–17.8). After data adjustment, the weighted
cognitive and functional impairment prevalence (n =
247.5) for the sample of 60-year-old or older subjects was
15.8% (95% CI 13.8–17.8).
Three months after the beginning of the first phase of
the study, the elderly subjects who were screen positives
for dementia (n = 250) and a random sample of subjects
negative for the dementia screening (n = 243) were in-
vited to an evaluation performed by the physicians at the
hospital (table 1). From the total of 321 elderly assessed,
24.6% (n = 79) were evaluated at home by the physicians.
The complete workup for dementia (including laboratory
exams and brain scans) was performed for 74.4% (n =
122) of the 164 subjects evaluated as screen positive for
dementia.
Table 1 shows that all subjects with cognitive and
functional impairment or screen positives for dementia

Dementia Prevalence in São Paulo, Brazil Dement Geriatr Cogn Disord 2008;26:291–299 293
were invited to the second phase, but only 164 were eval- Table 2. Prevalence of dementia, CIND and other neuropsychiat-
uated. The remaining 84 elderly who were not evaluated ric disorders (n = 1,563)
were compared to those actually investigated for de-
n Nonadjusted Adjusted
mentia. There were no significant differences between prevalence, % prevalence
the 2 groups regarding age (t = –0.72, p = 0.46), gender estimate1, %
(␹2 = 0.27, p = 0.60), educational level (␹2 = 8.89, p =
0.06), social class (␹2 = 4.91, p = 0.29), and scores on Dementia 107 6.8 (5.6–8.0) 12.9
the MMSE (t = 1.10, p = 0.31), FOME (t = 0.86, p = 0.38), CIND 25 1.6 (0.9–2.2) –
Other neuropsychiatric
IQCODE (t = 0.64, p = 0.52) and B-ADL (t = –1.71, p = disorders2 76 4.9 (3.8–5.9) –
0.08). Dementia in people aged
Of the 107 cases that received a diagnosis of dementia, ≥65 years (n = 1,186) 98 8.3 (6.7–9.9) 16.2
101 were screen positives, which means that the screening
CIND = Cognitively impaired not demented. Figures in pa-
instrument showed a sensitivity rate of 94.4% to identify
rentheses indicate 95% CIs.
the subjects with dementia. Of the 214 noncases of de- 1
Dementia prevalence rates adjusted for the design effect, the
mentia, 151 were screen negatives, resulting in a specific- nonresponse rate during the community phase and the positive
ity of 70.6%. Of the 164 elderly subjects invited as screen and negative predictive values of the screening instruments.
2
positives, 101 received a diagnosis of dementia, with a Aphasia, depression, dysthymia, mental retardation, anxiety
disorders, alcohol dependence.
positive predictive value of 61.6%. Of the 157 elderly as-
sessed as screen negative, 6 were diagnosed with demen-
tia, with a negative predictive value of 96.2%.
Considering the whole sample of 60-year-old or older
subjects, the prevalence rates (nonadjusted) of the main Table 3. Causes of dementia
diagnostic categories and the prevalence estimate of de-
mentia, calculated according to the formula presented n %
above [17], are shown in table 2. AD 64 59.8
Table 3 presents the etiologic diagnosis for 107 pa- VD 17 15.9
tients with dementia, made by consensus, according to AD + VD 9 8.4
DSM-IV criteria [15]. Magnetic resonance imaging scans Lewy body dementia 1 0.9
were obtained for 72 and computerized tomography Parkinson’s dementia 1 0.9
Alcoholic dementia 5 4.7
scans for 50 screen-positive subjects. Among the patients
Unspecified dementia 10 9.3
with scans, the most frequent diagnosis was Alzheimer’s
disease (AD; 50.8%), followed by vascular dementia (VD; Total 107 100
55.6%), AD + VD (75%), and nonspecified dementia
(25%). For those with incomplete data regarding labora-
tory and neuroimaging exams, diagnosis was performed
based on the clinical evaluation by a trained physician
using the previously described instruments and applying variables was 2.3%. Table 4 shows that, for the bivariate
the DSM-IV criteria. analysis, only the frequencies of the variables gender and
Considering the two most frequent causes of dementia skin color were not significantly different between the
we found in the sample of subjects older than 60 years groups.
(n = 1,563), the prevalence of AD was 4.1% (95% CI 3.1– The results of the multivariate analysis performed by
5.1) and the prevalence of VD was 1.1% (95% CI 0.6–1.6). logistic regression using weighted data are presented be-
In the sample of people older than 65 years (n = 1,186), low. Diagnosis of dementia was the dependent variable.
the prevalence of AD (n = 60) was 5.1% (95% CI 3.9–6.4), The total number taken into consideration for the analy-
and the prevalence of VD (n = 14) was 1.2% (95% CI sis was 1,452 elderly subjects since the dementia group
0.6–1.8). included 101 subjects and the group without dementia
Table 4 shows a comparison between patients with de- consisted of 1,351 subjects.
mentia (n = 107) and elderly subjects without dementia The following variables significantly increased the
(n = 1,370) regarding age, gender, schooling, skin color odds ratio of dementia in the multivariate analysis: age
and social class. The highest rate of missing data for these for subjects aged 70 years or older and illiteracy.

294 Dement Geriatr Cogn Disord 2008;26:291–299 Bottino et al.

 Table 4. Sociodemographic characteristics of the subjects with dementia compared to subjects without de-
mentia

Variables Subjects with Subjects without Subjects with Subjects without pc

dementia dementia dementia dementia
(weighted)a (weighted)b
n % n % n % n %

Age groups
60–64 9 2.4 359 97.6 10.9 3.2 329.0 96.8 <0.0001
65–69 13 4.1 307 95.9 16.4 5.6 277.2 94.4
70–74 22 7.1 289 92.9 26.8 8.9 274.6 91.1
75–79 24 9.5 228 90.5 33.4 13.0 223.4 87.0
80–84 17 13.3 111 86.7 22.4 16.1 116.5 83.9
85–89 11 15.3 61 84.7 15.9 20.5 61.6 79.5
≥90 11 42.3 15 57.7 15.9 48.9 16.6 51.1
Gender
Female 74 7.3 937 92.7 97.6 9.8 893.7 90.2 0.982
Male 33 7.1 433 92.9 44.1 9.8 405.1 90.2
Skin color
White 67 6.2 1,022 93.8 92.5 8.5 993.9 91.5 0.077
Brown 22 9.9 200 90.1 26.8 13.3 175.6 86.7
Black 13 11.9 96 88.1 15.7 16.0 82.2 84.0
Asian 3 5.7 50 94.3 4.2 8.6 45.3 91.4
Educational level
Illiterate 43 18.7 187 81.3 52.5 24.6 161.2 75.4 <0.0001
1–4 years 42 6.7 582 93.3 54.4 9.5 518.2 90.5
5–8 years 5 2.7 179 97.3 8.0 4.4 173.3 95.6
9–11 years 6 4.1 139 95.9 8.8 5.7 143.9 94.3
≥12 years 9 3.1 282 96.9 15.8 5.0 301.3 95.0
Social class (ABIPEME)d
A 2 2.9 68 97.1 3.6 4.7 72.3 95.3 <0.0001
B 24 5.2 441 94.8 35.9 7.4 450.6 92.6
C 25 5.1 467 94.9 34.7 7.5 430.3 92.5
D 32 10.7 266 89.3 40.9 14.8 234.5 85.2
E 21 15.8 112 84.2 23.2 19.2 97.6 80.8
a Subjects with cognitive and functional impairment weighted for the design and nonresponse effect during

the home phase.

b
Subjects without cognitive and functional impairment weighted for the design and nonresponse effect dur-
ing the home phase.
c Rao-Scott ␹2 , comparing the weighted frequencies in each variable.
d ABIPEME: Brazilian Association of Market Research.

Discussion elderly the prevalence estimate was 16.2%. The initial

The dementia prevalence we found in the 60-year-old
or older elderly was 6.8%, and the 65-year-old or older
subjects showed a prevalence of 8.3%. Considering the
design effect, the nonresponse rate during the commu-
nity phase and the formula that uses positive and nega-
tive predictive values of the screening instruments, the
adjusted prevalence estimate of 60-year-old or older
subjects was 12.9%, and for the 65-year-old and older
adjustment (design effect and nonresponse during the
community phase) did not have a significant influence
on the prevalence rates of cognitive and functional im-
pairment [6], but the estimated prevalence rates of de-
mentia presented an important increase compared to
the dementia prevalence we found. The multivariate
analysis showed an association of dementia with so-
ciodemographic variables, such as older age and illiter-
acy.

Dementia Prevalence in São Paulo, Brazil Dement Geriatr Cogn Disord 2008;26:291–299 295
 Reviewing studies on dementia prevalence in the com-
munity [20], we found a prevalence rate of dementia of
around 6% for 65-year-old or older subjects. Therefore,
this rate is lower than the nonadjusted and adjusted prev-
alence rates found in the present study. However, higher
prevalence rates of dementia found in samples of 65-year-
old or older subjects have also been demonstrated in a
study conducted in Belgium [21], with a rate of 9%; in two
studies carried out in Spain, with rates of 13.9 and 14.9%,
respectively [22, 23]; in a Japanese study with a rate of
8.5% [24]; in two Korean studies with rates of 8.5 and
9.5%, respectively [25, 26], and in a study from the USA,
with an estimated rate of 9.6% [27]. Another study per-
formed in Spain, with a population older than 70 years,
presented a prevalence rate of 17.7% [28]. A common
characteristic of some of these studies is the fact that they
have been conducted, exclusively or partially, in rural
samples (e.g. the Korean [25], the Spanish [22, 23], and the
Japanese [24] study). It is possible to suppose that these
elderly subjects have less access to health services and/or
have a higher number of clinical comorbidities, which
may partially explain the high rates. On the other hand,
the mean prevalence of dementia for 65-year-old or older
subjects was significantly lower in Africa, in Asia it ranged
from 2.2 to 5.7% [20], and the only Latin American study
[7] included in our review showed a dementia prevalence
rate of 7.1%.
Other community-based studies of dementia preva-
lence in Latin American countries were published in the
last few years, such as a recent study from Venezuela [29],
reporting rates of 8.0% for subjects 55 years and older,
and 13.2% for those 65 years and older. Another study
was conducted in Cuba [30], with a prevalence rate of
8.2–11.2%, considering 60-year-old or older subjects. In
samples of subjects older than 65 years, a prevalence of
11.5% was reported in Argentina [31], and Brazilian stud-
ies have shown rates of 7.1% [7] and 2% [32]. Finally, one
study conducted in Colombia [33] showed a prevalence
of 3.4% for those 75 years and older. Therefore, only two
of these studies [32, 33] have demonstrated significantly
lower rates if compared to the other Latin American
studies, one [32] employing a new case-finding method
for dementia screening through community health
workers, and the other [33] estimating dementia from a
relatively small sample (n = 238). On the other hand, in
two studies [29, 31] showing a prevalence rate similar to
the present report, the total sample selected was inter-
viewed. In the Brazilian study by Herrera et al. [7], per-
formed in two phases, the screen negatives have not been
assessed, which makes it impossible to calculate the neg-
296 Dement Geriatr Cogn Disord 2008;26:291–299
ative predictive value. However, since the positive pre-
dictive value was 54%, the estimate of dementia preva-
lence (665 years old) would have been 11.9% with a hy-
pothetical negative predictive value of 95%, or 16.2%
with a negative predictive value of 90%. Therefore, it is
possible to assume that by adjusting the prevalence esti-
mates in two-phase studies or by assessing the entire el-
derly sample of representative populations from the Lat-
in American countries in a rigorous manner, we would
find higher prevalence rates such as those found in the
present study.
In an important review of the literature [4], the neces-
sity of more epidemiological studies on dementia in Lat-
in America, Russia, Eastern Europe, the Middle East, and
Africa has been highlighted. For Latin America, a preva-
lence rate of dementia (660 years old) of 4.6% has been
calculated based on only one study in the region, which
seems to be the Brazilian study by Herrera et al. [7]. We
agree with the first conclusion of this systematic review
of the literature, but we believe that the prevalence rate of
dementia found for Latin America has been underesti-
mated. Based on that hypothesis, we assume that there
will probably be a higher increase in the number of el-
derly individuals impaired by this disease in the next few
years, unless effective strategies of prevention are imple-
mented.
In the 60-year-old or older sample we evaluated, the
prevalence of AD was 4.1%, and the VD prevalence was
1.1%. In the 65-year-old or older sample, the prevalence
of AD was 5.1%, and the VD prevalence was 1.2%. In the
review of the literature mentioned above [20], the propor-
tion AD:VD was higher than 4:1 in the Western coun-
tries, which is in agreement with another Brazilian study
[7] and the present research. In most of the Latin Ameri-
can studies cited, as well as in the present report, AD
cases represented 50–62.5% of all the subjects with de-
mentia [7, 29, 30, 32]. However, the frequency of VD cas-
es varied greatly, ranging from 9.3 to 31.1% in the same
studies. In the present report, as neuroimaging and labo-
ratory exams were available for only 74.4% of the sample
with dementia, it is possible that VD and AD + VD cases
were underestimated. In a review of 15 studies on the
prevalence of AD [34], the authors have pointed out that,
after controlling for the influence of age, 76% of the vari-
ance found could be explained by characteristics such as
inclusion of mild cases, use of laboratory tests and cra-
nial computerized tomography, sample composition, use
of Hachinski’s Ischemic Scale, and correction for false
negatives. Therefore, we may suppose that some of these
characteristics might have been responsible for the differ-
Bottino et al.
ences in the prevalence rates of the main etiologies of de- Table 5. Regression model with sociodemographic variables
mentia in the cited studies.
In the present study, the dementia rates increased with Variables OR 95% CI Wald p
age, going from 3.2% for subjects in the 60- to 64-year age Age groups
group to 48.9% for those aged 95 years and older. The 60–64 1.00
odds ratio of dementia was significantly associated with 65–69 1.62 0.69–3.84 1.2 0.2697
age for elderly aged 70 years and older. Age is the most 70–74 2.61 1.25–5.45 6.5 0.0109
important risk factor for dementia. In a review of 12 stud- 75–79 4.19 1.99–8.81 14.2 0.0002
80–84 6.74 2.94–15.46 20.3 <0.0001
ies on the incidence of dementia and AD [35], the authors 85–89 7.51 2.89–19.50 17.2 <0.0001
reported an acceleration of the rates for AD and dementia >90 34.93 11.42–106.85 38.8 <0.0001
which slowed down with age, but without evidence of a Educational level
rate decline. Age was also identified as a factor associated ≥12 years 1.00
with dementia prevalence rates in Latin American stud- Illiterate 5.33 2.08–13.68 12.1 0.0005
1–4 years 2.23 0.92–5.44 3.1 0.0768
ies, such as those conducted in Cuba [30], Brazil [7, 32] 5–8 years 0.97 0.32–2.91 0.0 0.9514
and Colombia [33]. 9–11 years 1.42 0.46–4.38 0.4 0.5382
Illiteracy was significantly associated with dementia in Gender
our sample, and low schooling levels were also associated Male 1.00
with diagnosis of dementia in two Latin American studies Female 0.86 0.54–1.38 0.4 0.5317
Skin color
[7, 33]. In a recent meta-analysis [36], 13 cohort and 6 case- White 1.00
control studies were reviewed to investigate education as Brown 1.29 0.71–2.36 0.7 0.4041
a risk factor for dementia. The relative risks for low versus Black 1.50 0.76–2.96 1.3 0.2465
high education level were 1.80 for AD, 1.32 for non-AD Asian 0.97 0.20–4.67 0.0 0.9735
dementias, and 1.59 for all dementias. Comparing low and Social class (ABIPEME)
A 1.00
medium versus high education level, the relative risks B 1.43 0.34–5.96 0.2 0.6233
were: 1.44 for AD, 1.23 for non-AD, and 1.33 for all de- C 1.04 0.23–4.70 0.0 0.9610
mentias. Therefore, these results suggest that low educa- D 1.60 0.33–7.72 0.3 0.5569
tion may be a risk factor for dementia, especially for AD. E 2.05 0.42–10.02 0.8 0.3750
Gender, skin color, and social class were not associated
OR = Odds ratio of dementia; 95% CI = 95% confidence inter-
with dementia in the multivariate analysis reported in val of the OR; ABIPEME = Brazilian Association of Market Re-
table 5. An association between female gender and de- search.
mentia was reported in many Latin American studies [7,
30, 32, 33], while this was not the case in other studies [29,
31]. In the incidence study conducted in Brazil [37], gen-
der was not associated with AD as it was in the prevalence
study [7], but the incidence of dementia was higher in ysis of our sample, but that association disappeared in
women older than 85 years. These divergent findings re- the multivariate analysis, probably because illiteracy re-
garding female gender and dementia corroborate the mained significantly related to dementia, as education
controversy about gender as a risk factor for dementia was considered in the scale applied to classify subjects in
and AD [38]. Regarding skin color, the marginally sig- 1 of the 5 socioeconomic levels. In a cohort of 931 elderly
nificantly (p = 0.077) higher dementia rates in the elderly subjects in Sweden, followed for 3 years, less educated
classified as brown or black in the bivariate analysis lost subjects as well as subjects with a lower socioeconomic
significance in the multivariate analysis performed in status had a higher risk of developing AD [40]. However,
our sample. However, in a multiethnic community in the when both education and socioeconomic status were in-
USA, age, family history of AD and African-American or troduced into the model, only education remained sig-
Cuban ethnic group were directly and independently as- nificantly associated with AD, similar to what we found
sociated with prevalence of AD, suggesting that further in a cross-sectional study.
studies should address the relationship between ethnicity The cluster sampling applied in the present study
and environmental factors in the occurrence of AD and aimed to evaluate a sample selected from three different
dementia [39]. Finally, lower socioeconomic class was sig- socioeconomic classes (upper, middle and low) in São
nificantly associated with dementia in the bivariate anal- Paulo, which is comparable to the general elderly popula-

Dementia Prevalence in São Paulo, Brazil Dement Geriatr Cogn Disord 2008;26:291–299 297
tion living in São Paulo, with a possible excess of women
and elderly with higher educational levels. A limitation of
our study is the response rate of 70%. However, another
community-based study performed in São Paulo [41] had
a response rate of 65.2%. In other studies that investigat-
ed the prevalence of dementia, such as in Australia [42],
in Denmark [43] and in Japan [44], the response rates
were 68.6, 64.6, and 75.7%, respectively. Therefore, the
response rate obtained during the field phase of our study
was similar to the rate found in other studies involving
elderly individuals in Brazil (and in the city of São Paulo),
as well as in developed countries. Another limitation of
the present study is the response rate of the second phase
of 65.6%. However, the lack of differences between the
subjects selected and those actually examined suggests
that examining all the elderly screen positives for demen-
tia would not substantially change our results.
In short, the estimate of dementia prevalence in the
community-dwelling elderly living in São Paulo was
higher than previously reported in Brazil, with AD and
VD being the most frequent causes of dementia. Sociode-
mographic factors, such as older age (670 years old) and
illiteracy, were significantly associated with dementia.
Moreover, the prevalence of dementia in elderly people
from Latin America might also be higher than previous-
ly reported and additional studies need to further inves-
tigate this issue. Latin American countries might have to
be prepared to increase health service provisions, if high-
er dementia rates were confirmed in other countries of
this region.
Acknowledgments
The authors would like to thank the elderly people from São
Paulo who accepted to participate in this research. The authors
would also like to thank Prof. Mariana Curi for statistical assis-
tance. This study was supported by ‘Fundação de Apoio à Pes-
quisa do Estado de São Paulo’ (FAPESP), grant No. 01/05959-7.

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