Rev Med (São Paulo). 2015 jul.-set..;94(3):154-61.

doi: http://dx.doi.org/10.11606/issn.1679-9836.v.94i3p154-161

Prevalence of dementia among brazilian population: systematic review

Revisão sistemática sobre prevalência de demência entre a população brasileira

Mario Sergio Boff1, Felipe Seiti Sekyia2, Cássio Machado de Campos Bottino3

Boff MS, Sekyia FS, Bottino CMC. Prevalence of dementia among brazilian population: systematic review / Revisão sistemática sobre
prevalência de demência entre a população brasileira. Rev Med (São Paulo). 2015 jul.-set.;94(3):154-61.

ABSTRACT: As the elderly population increases worldwide, the RESUMO: À medida que a população idosa aumenta no mundo,
age-related diseases, particularly dementia, become more frequent. as doenças relacionadas ao envelhecimento, particularmente a
Knowing that Brazil follows the global trend of aging, it should demência, tornam-se mais frequentes. Tendo em vista que o Brasil
also present an increasing prevalence of dementia. Objectives: segue essa tendência global do envelhecimento populacional, deve
the aims of this study are to review the articles of prevalence apresentar, também, aumento da prevalência de demência em
of dementia in Brazil in recent years, establish comparisons sua população. Objetivos: os objetivos desse estudo são revisar
between the studies and identify associations between the artigos sobre prevalência de demência no Brasil nos últimos anos,
dementia prevalence and the population characteristics. Data estabelecer comparações entre os estudos e identificar associações
sources: SciELO, Lilacs and Medline. Methods: retrieving from entre a prevalência de demência e características populacionais.
original articles about epidemiological studies on prevalence of Bases de dados: SciELO, Lilacs e Medline. Métodos: pesquisa
dementia among Brazilian population samples using specific por artigos originais sobre estudos epidemiológicos de
keywords, exclusion of duplicates, screening, full text assessment prevalência de demência em amostras populacionais brasileiras,
and characterization of the selected studies’ population samples. usando especificas palavras-chaves nas bases de dados com
Results: from the 357 articles retrieved, only 8 remained after três fases de seleção final dos artigos e caracterização daqueles
the assessment. The prevalence found in the selected articles selecionados. Resultados: dos 357 artigos encontrados, apenas 8
ranged from 5.1% to 17.5%. Discussion: despite the good quality foram selecionados após a avaliação. A prevalência encontrada
of the articles, the small number of selected studies essentially nos artigos variou de 5,1% a 17,5%. Discussão: apesar da boa
conducted in the southeast region of Brazil is insufficient for an qualidade dos artigos, o pequeno número deles é insuficiente para
epidemiological characterization of the Brazilian population as caracterizar a população brasileira. A doença de Alzheimer é a
a whole. Alzheimer’s disease subtype is shown to be the leading causa de demência que lidera em número de casos e a associação
cause of dementia and an association between dementia and age entre demência e idade é demonstrada, assim como escolaridade.
is demonstrated, as well as schooling. Conclusion: more studies Conclusão: são necessários mais estudos de outras regiões do
from other regions of Brazil are necessary to better evaluate the Brasil para avaliar e comparar a população brasileira com outras
prevalence of dementia and to investigate the more important populações.
factors associated with this disease.
Descritores: Epidemiologia; Prevalência; Demência/epidemiologia;
Keywords: Epidemiology; Prevalence; Dementia/epidemiology; Brasil/epidemiologia.
Brazil/epidemiology.

Artigo Desenvolvido na Disciplina Optativa “Abordagem Prática da Escrita Científica” sob coordenação da Revista de Medicina do
DC-FMUSP.
1. Medical student, Faculty of Medicine, University of São Paulo, Brazil. E-mail: [email protected].
2. Medical student, Faculty of Medicine, University of São Paulo, Brazil. E-mail: [email protected].
3. Associate Professor, Old Age Research Group (PROTER), Institute and Department of Psychiatry, Faculty of Medicine, University
of São Paulo, Brazil. E-mail: [email protected].
Address: Mario Sergio Boff. Rua Santo Ubaldo, 28, apto 31F. Vila Palmeiras, São Paulo, SP, Brazil. E-mail: [email protected].

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INTRODUCTION Saúde) and MEDLINE (Medical Literature Analysis and

Retrieval System Online), using the following keywords:
“epidemiology” (used only in LILACS), “prevalence”,

S ince the early 20th century, the world has

been undergoing an accelerated process of
demographic transition, with a reduction in birth rates and
“dementia” and “Brazil”.
To analyze the results from databases we followed
three steps:
an increase in life expectancy. In Brazil it has not been 1. Exclusion of duplicates;
different1. While fertility has fallen around 50% between 2. Reading of the title, year of publication and
1970 and 2000, the elderly population has increased from abstract (screening);
5.1% to 8.6 % over the same period. In addition, the average
3. A full text assessment.
annual growth rates of the elderly have been the highest
among the age groups, reaching values greater than 3%. Reviews, editorials and articles out of the
It is estimated that in 2045, the elderly population will established period, studies with non community-based
have passed the child population2. Given this situation, it samples and articles whose main objective was not the
is expected that the epidemiological profile of Brazil will investigation of dementia were excluded. The languages
also suffer major changes, with increased occurrence of accepted were English and Portuguese. Two independent
age-related diseases. examiners made the selection on MEDLINE database
Dementia is one of the main diseases of age, (M.S.B. and F.S.S.). Furthermore, the examiners screened
counting in 2010 with more than 35 million cases the references of other systematic reviews to find any other
worldwide. For being a debilitating disease, the impact studies that were not found in databases.
to the individual and his family is very strong, both in
emotional terms, as economic. It is estimated that the world Characterization and description
spent on dementia was 604 billion dollars in 2010, which
only tends to grow in the coming years, since the number The following variables were included in
of cases will triple by 20503. This is especially important the qualitative analysis: author, year of publication,
in the Brazilian context, because, as Brazil has followed city, sample, age of studied population, prevalence of
the global trend of aging, it should also follow the trend dementia, diagnostic instruments, sample data available
of dementia cases, which will require greater government and evaluation of dementia (subtypes and severity).
attention and better trained health professionals. Furthermore, a brief summary of each study was made
The aims of this study are: and compiled with the most important information about
1. to find and select original articles about methods and results.
prevalence of dementia among Brazilian population
published between 2000 and 2014 on online databases;
RESULTS AND DISCUSSION
2. to analyze the data from the articles and
compare the results with studies from other countries; Articles findings and selection
3. to analyze the associated factors found in the
studies of dementia prevalence.
A total of 357 references were found (17 from
SciELO, 58 from Lilacs and 282 from Medline): 46
references were excluded for being duplicated (1º step);
METHODS
311 were evaluated by title, period, abstract and type
of article (screening) and 256 were excluded (2º step),
Survey and Selection resulting in 15 articles, which were fully read. From the
full-text assessment (3º step), 7 articles were excluded (3
Search was done in January 2015 for original studies about cognitive and functional impairment that do
articles published between January 2000 and December not diagnose dementia4-6, 1 study with ambulatory sample7,
2014 that present epidemiological studies on the prevalence 1 clinicopathologic study8, 1 study about dementia risk
of dementia among samples of the Brazilian population. factors9 and 1 study about incidence of dementia10. No
The search occurred on electronic databases, including additional papers were identified from others references
SciELO (Scientific Electronic Library Online), LILACS and just 8 articles remained after full reading, then going
(Literatura Latino-Americana e do Caribe em Ciências da for qualitative analysis (Figure 1).

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Figure 1. Flow of information through the different phases of the systematic review

Characterization The community sample was randomly selected from three

districts with different social class. This two-phase survey
The studies have, in general, a similar characteristic was conducted in the 2000 decade. The first phase screened
regarding the methods (design) and sample analyzed. The the subjects with MMSE, FOME, IQCODE and B-ADL
populations were studied in three different decades (1990, instruments. The second phase diagnosed the subjects
2000 and 2010). From the eight articles, seven were from according to the CAMDEX and DSM-IV criteria. The
southeast region of Brazil, more specifically from the prevalence found was 6.8%, but it rose to 12.9% when
states of São Paulo and Rio de Janeiro, whereas only one adjusted to the study design. The subtypes of dementia were
study was made in Mato Grosso do Sul. In all selected evaluated. Aging and schooling were reported as associated
articles, population samples have more than 60 years and factors for dementia.
half of them included a large number of participants (over Lopes et al.16: study conducted in Ribeirão Preto
1000). Demographic characteristics of population such city, with sample of 1145 subjects aged 60 years old or
as age group, gender, schooling, skin color, social class, more. The design of the sample selection and the analysis
marital status, income and birth area are present in the (screening and diagnosis criteria) were the same applied in
articles. Regarding the methods used, basically, the studies Bottino et al., 2008. The two-phase survey was conducted
applied the CAMDEX and DSM-IV criteria for diagnostic in the 2000 decade. The prevalence found was 5.9%
of dementia, evaluating, mainly, the subtypes (Alzheimer and, when adjusted, rose to 12.5%. The study evaluated
disease and vascular dementia). In this review, we found dementia subtypes and found association of dementia with
prevalence values ranging from 5.1% to 17.5%. These basic aging and schooling.
characteristics of the studies are presented in the Table 1. Correa et al.17: study conducted in Rio de Janeiro
city, with sample of 683 subjects aged 67 years old or
Description of studies more, clients of a private health plan. A two-phase survey
was done in the 2010 decade. The screening phase applied
Bottino et al.15: study conducted in São Paulo city, the MMSE and FAQ questionnaires and the diagnosis of
with sample of 1563 subjects aged 60 years old or more. dementia was made following the DSM-IV criteria. The

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prevalence found was 16.9%. The study evaluated subtypes aged 65 years old or more. The evaluation of dementia was
of dementia and showed an association with ageing and made by the 10/66 Dementia Re-search Group protocol
schooling, with the prevalence ratio (raw and adjusted). in the 2000 decade. The prevalence found was 5.1%.
Scafuza et al.18: study conducted in São Paulo city, Ageing, schooling and income were associated to dementia.
designed with only one phase that assessed 2072 subjects Dementia subtypes were evaluated.

Table 1. Data of the included studies

Diagnostic Evaluation of
Author Year City Sample Age Prevalence1 Sample data
instruments dementia

Bottino et al. 2008 São Paulo, SP 1563 ≥60 107 (6.8%) zx abcde subtypes

Correa et al. 2013 Rio de Janeiro, RJ 683 ≥65 115 (16.9%) x abcfg subtypes

Individual
Cesar et al. 2014 Tremembé, SP 630 ≥60 110 (17.5%) abce -
analysis

Herrera et al. 2002 Catanduva, SP 1656 ≥65 118 (7.1%) xw abcde subtypes, severity

Scazufca et al. 2008 São Paulo, SP 2072 ≥65 105 (5.1%) x abcfgh subtypes

Lopes et al. 2012 Ribeirão Preto, SP 1145 ≥60 68 (5.9%) zx abceg subtypes

São Paulo
Meguro et al. 2001 166 ≥65 13 (7.8%) x bc subtypes, severity
metropolitan area

Yamada et al. 2002 Campo Grande, MS 157 ≥70 19 (12.1%) y c subtypes

Legend: Sample data: (a) gender, (b) schooling, (c) age group, (d) skin color, (e) social class, (f) income, (g) marital status and (h) birth area. Diagnostic instruments: (z)
“Cambridge Mental Disorders of the Elderly Examination” (CAMDEX)10, (y) “Diagnostic and statistical manual of mental disorders,3rd ed. rev” (DSM-III-R)11, (x) “Diagnostic
and statistical manual of mental disorders, 4th ed.” (DSM-IV)12 and (w) “Clinical Dementia Rating” (CDR)13. 1Prevalence in number of cases and percentage.

Herrera et al.19: study conducted in Catanduva with 630 subjects aged 60 years or more, in 2010 decade.
city with 1656 subjects aged 65 years old or more that was The subjects were assessed by clinic, neurologic and
randomly selected. The screening phase applied MMSE and psychiatric evaluation and questionnaires were applied. The
PFAQ questionnaires and the diagnostic phase followed the prevalence found was 17.5%, with association of ageing
DSM-IV criteria. The sample was assessed in 1990 decade. and schooling.
The prevalence found was 7.1%, evaluating subtypes. The studies selected have a good quality, so it is
Ageing, schooling and female gender were associated possible to make comparisons between them. Otherwise,
with dementia. there are studies only from two regions, and the Brazilian
Meguro et al. 20: study conducted with 192 population is not widely analyzed. Only the population of
Japanese immigrants aged 65 years or more in the São the São Paulo state is reasonably studied. This scenario is
Paulo metropolitan area. The diagnosis was made following the same of other developing countries, like China, India,
DSM-IV criteria and the severity was assessed by CDR Egypt, South Africa, and the countries from Latin America
scale. The prevalence found was 7.8%. The very older and Caribe, which have insufficient epidemiological studies
subjects and, in contradiction, the high level of education to characterize their population23.
showed more elevated rates of dementia.
Yamada et al. 21: study conducted in Campo Prevalence of dementia
Grande city with 157 subjects from a Japanese-Brazilian
community. The subjects are 70 years old or more. The In Table 2, the prevalence of dementia among
two-phase survey was made in 2000 decade. The phase population aged 65 years or more is showed by age group
of screening applied MMSE and the diagnosis was made in some studies. The mean prevalence among these studies
following DSM-III-R criteria. The subtypes were evaluated. is 11.15%. In 2001, the prevalence estimates for Latin
César et al.22: study conducted in Tremembé city, America was 4.6%23, and, to 2013, this estimate almost

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doubled to 8.5%3, following the trend of developing The prevalence rates found in the Brazilian studies
countries (increasing elderly population and the prevalence have a wide interval between than (5.1% to 17.1%) and
of dementia). Despite of the higher prevalence found in the mean prevalence of the Brazilian studies shows much
Brazilian population, the rates are similar to other Latin higher prevalence rates than other regions of the world27,
America and Caribbean (LAC) studies. In Chile, the rate as the LAC rates, that can possibly be explained by sample
found is 7.0%24, in Argentina, 8.3%25, in Mexico, 8.5 to characteristics (mean age, income, race etc.) and difference
8.6%, in Cuba 10.8% and in Peru, 6.5 to 9.3%26. in the studies design and methods28.

Table 2. Absolute number of individuals with dementia in each age group

Bottino et al. Correa et al. Cesar et al. Herrera et al. Scazufca et al. Lopes et al.
n d n d n d n d n d n d
Age groups
65-69 320 13 79 3 152 16 614 10 889 20 267 6
70-74 311 22 163 8 117 18 470 15 556 11 238 15
75-79 252 24 158 14 101 27 266 21 346 27 156 15
80-84 128 17 154 27 63 19 198 30 169 23 84 13
≥85 98 22 129 63 45 22 108 42 112 24 44 13
Total 1109 98 683 115 478 102 1656 118 2072 105 789 62
Prevalence 8.8% 16.9% 21.3% 7.1% 5.1% 7.8%
Legend: n) sample and (d) cases with dementia.

Dementia subtypes very different between the studies, but all show AD as
the most frequent cause of dementia. A great number of
Regard the evaluation of dementia, most of the studies and reviews present AD with the most prevalent
studies evaluate three dementia subtypes: Alzheimer’s dementia subtype, despite of the variability of the rates
disease (AD), vascular dementia (VD) and mixed dementia worldwide27-29. Brazilian people trends to get higher
(AD + VD). The rate between the subtypes prevalence is prevalence of AD, like developed countries.

Legend: AD: Alzheimer disease; VD: vascular dementia; AD + VD: mixed dementia.

Figure 2. Proportion of the dementia subtypes diagnosed in each study

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Associated factors is more significant above 80 years old. Figure 4, also,

shows a gradient with schooling and a higher prevalence
Association between dementia and age was among illiterates. Aging and illiteracy are well correlated
demonstrated in all studies; as well as schooling (not with dementia among several studies in developed and
analyzed in Yamada et al.21). In Figure 3, the prevalence developing countries and presents as the most important
variation regarding the age groups shows a gradient that associated factor to cognitive impairment24,30.

Figure 3. Prevalence of dementia by age groups

Figure 4. Prevalence by schooling

Association with gender is positive in some association found in some studies27,29. The strength of
studies, but negative in others, so it is not possible to association is assessed by effect measures like odds ratio
establish gender as an associated factor to dementia by this and prevalence ratio to some of the sample data. As Table 3
or other prevalence of dementia reviews27. Sociocultural shows, the strength of association is significant (CI higher
factors for women, that, in general, has higher life than 1) to age groups older than 80 years and the illiterates
expectancy and less years of education can explain the in part of the studies.

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Table 3. Strength of association between age/schooling and dementia

Bottino et al. Lopes et al. Scafuza et al. Correa et al.

Odds Ratio (95% CI)
Age groups
60-64 years 1.00 1.00
65-69 years 1.62 (0.69-3.84) 0.5 (0.13–1.87) 1.00 1.00
70-74 years 2.61 (1.25-5.45) 2.29 (0.74–7.12) 0.88 (0.42–1.84) 1.07 (0.29-3.87)
75-79 years 4.19 (1.99-8.81) 2.64 (0.80–8.66) 3.68 (2.03–6.65) 2.03 (0.61-6.81)
80-84 years 6.74 (2.94-15.46) 6.73 (2.14–21.13) 6.84 (3.66–12.78) 3.93 (1.24-12.43)
85-89 years 7.51 (2.89-19.50) 7.92 (1.47–37.31) 9.17 (2.96-28.45)
≥90 years 34.93 (11.42-106.85) 29.91 (7.12–125.53) 13.89 (4.51-42.74)
Schooling
Illiterate 5.33 (2.08–13.68) 3.94 (1.23–12.60) 6.48 (3.44-12.21)
1-4 years 2.23 (0.92–5.44) 1.67 (0.61–4.54) 4.09 (2.34-7.18)
5-8 years 0.97 (0.32–2.91) 1.98 (0.55–7.01) 2.84 (1.59-5.09)
9-11 years 1.42 (0.46–4.38) 1.36 (0.38–5.04)
≥12 years 1.00 1.00 1.00

CONCLUSION studies in the others regions from Brazil. Thus, this revision
does not represent the real situation of the Brazilian elderly
The studies shows a large variation in prevalence population, but is very important considering the state of
rates (range of raw rates: 5.1% to 17.5%). The difference São Paulo.
between the rates can be justified by: the difference between More studies from other regions from Brazil are
population (regarding area and period of studies), the necessary to assess their elderly population and compare
sample number and the methods applied (one phase or two with other countries. Future studies must investigate other
phase; screening and diagnostic instruments). associated factors, a better characterization of the sample
The majority of studies selected were from the and designs that can allow better dementia prevalence
Southeast region, what shows a lack of cross-sectional estimates.

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