Journals of Gerontology: Medical Sciences

cite as: J Gerontol A Biol Sci Med Sci, 2023, Vol. 78, No. 6, 1060–1068
https://doi.org/10.1093/gerona/glad025

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Advance Access publication January 22, 2023

Research Article

Prevalence of Dementia and Cognitive Impairment No

Dementia in a Large and Diverse Nationally Representative
Sample: The ELSI-Brazil Study
Laiss Bertola, PhD,1,7,*, Claudia Kimie Suemoto, MD, PhD,2
Márlon Juliano Romero Aliberti, MD, PhD,3,4, Natalia Gomes Gonçalves, PhD,5
Pedro José de Moraes Rebello Pinho, MD,1 Erico Castro-Costa, MD, PhD,6
Maria Fernanda Lima-Costa, MD, PhD,6 and Cleusa P. Ferri, MD, PhD1,7
1
Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil. 2Division of Geriatrics,
University of Sao Paulo Medical School, São Paulo, Brazil. 3Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico
de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil. 4Research Institute,
Hospital Sirio-Libanes, Sao Paulo, Brazil. 5Department of Pathology, University of São Paulo, São Paulo, Brazil. 6Núcleo de Estudos em
Saúde Pública e Envelhecimento—Fundação Oswaldo Cruz e Universidade Federal de Minas Gerais, Belo Horizonte, Brazil. 7Health
Technology Assessment Unit—Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.

*Address correspondence to: Laiss Bertola, PhD, Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo,
Rua Major Maragliano, 241—Prédio Acadêmico, Vila Mariana Sao Paulo, SP CEP 04017-030, Brazil. E-mail: laiss.bertola@unifesp.br

Received: May 17, 2022; Editorial Decision Date: January 13, 2023

Decision Editor: Lewis Lipsitz, MD, FGSA

Abstract
Background: Approximately 77% of older adults with dementia in Brazil have not been diagnosed, indicating a major public health issue.
Previous epidemiological dementia studies in Brazil were based on data from 1 geopolitical region.
Methods: We aimed to estimate the general and subgroup-specific (age, education, and sex) prevalence of dementia and cognitive impairment
no dementia (CIND) classification using data from 5 249 participants aged 60 years and older from the ELSI-Brazil, a large nationally
representative sample. Participants were classified as having normal cognitive function, CIND, or dementia based on a combination of the
individual’s cognitive and functional status.
Results: We found a general prevalence of 5.8% (95% CI = 4.7–7.2) for dementia and 8.1% (95% CI = 6.8–9.5) for CIND. Dementia
prevalence ranged from 3.2% (60–64 years old) to 42.8% (≥90 years old) by age, and from 2.1% (college level or higher) to 16.5% (illiterates)
by education. Females had a higher dementia prevalence (6.8%) than males (4.6%). CIND prevalence was similar across age, sex, and
education.
Conclusions: The estimated dementia prevalence is lower than that in previous Brazilian epidemiological studies, but is in line with other Latin
American studies. Only 1.2% of the ELSI-Brazil participants reported having a previous diagnosis of dementia, revealing that underdiagnosis is
rampant and a common reality. Based on our results and national statistics projections, we estimate that in 2019, there were 1 757 480 people
aged 60 years and older living with dementia in Brazil and, at least, another 2 271 314 having to deal with some form of cognitive impairment.
Keywords: Diagnosis, Epidemiology, Low- and middle-income country

The global prevalence of dementia is expected to increase from 57.4 (LA) reveal considerable variability, ranging from 2% to 17%, but the
million cases in 2019 to 152.8 million cases in 2050 (1), and most estimated prevalence rates usually exceed the international average
people with dementia will be living in low- and middle-income coun- (3–5). Brazil is the largest country in LA and is expected to have the
tries (LMICs) (2). Dementia prevalence studies from Latin America most cases and experience the most significant dementia burden (6).

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Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6
Only a few studies on dementia prevalence have been conducted
in Brazil and nearly all of them in the state of Sao Paulo, and are,
therefore, not representative of the whole country. These studies re-
ported dementia prevalence rates ranging from 2.0% to 49.6% (7).
For example, Ramos-Cerqueira and colleagues (8) found a crude
prevalence of 2.0% when studying a sample of 2 222 older adults
aged 65 and over. Herrera Jr. et al. (9) found a crude prevalence
of 7.1% when studying a population sample of 1 656 older adults
also aged 65 or over. César et al. (10) found a 17.5% prevalence for
dementia and a 19.5% prevalence for cognitive impairment no de-
mentia (CIND) in a sample of 630 individuals aged over 60, from
a specific municipality. Some of these community-based studies are
considered reliable dementia prevalence estimates as they are based
on robust clinical evaluation and use accepted diagnosis criteria, but
none of them is representative of the Brazilian population (11).
However, considering that Brazil is a large, socioeconomically,
and culturally diverse country, data from studies in specific regions
probably do not reflect the reality for the whole Brazilian older
population. We aimed to estimate the prevalence of older adults with
possible dementia and CIND and perform projections based on na-
tional population estimations using data from a large and represen-
tative sample of Brazilians aged 60 years and older.
Method
Study Participants
We used baseline data from the Brazilian Longitudinal Study of
Aging (ELSI-Brazil), a nationally representative, population-based
cohort study of people aged 50 years or older (12). The study base-
line, conducted in 2015–2016, included 9 412 adults aged 50 years
and older from 70 municipalities representing small, medium, and
large cities in urban and rural areas of the 5 Brazilian geopolitical
regions. Trained interviewers performed the home-based interviews
that included comprehensive information on sociodemographic fac-
tors, lifestyle, mental and physical health, health resources utiliza-
tion, and physical performance tests (12). The ELSI-Brazil is the first
Health and Retirement Studies (HRS) partner study cohort in South
America. The HRS partner studies are designed to explore the de-
terminants of aging and its consequences for individuals and their
societies.
The research ethics committee of the Fundação Oswaldo Cruz
approved the original study, and informed consent was obtained
from all participants. The present analysis was conducted using the
publicly available deidentified ELSI-Brazil data set and had the ap-
proval of the Research Ethics Committee of the Federal University
of Sao Paulo.
For this study, we restricted our analysis to those aged 60 years
and older as our aim was to verify dementia and CIND prevalence
in older adults. We also excluded eligible participants with missing
classification status (normal, CIND, dementia) (n = 183) due to
missing variables used to create the groups. The final sample con-
sisted of 5 249 participants. The sociodemographic characteristics
of the study participants were broadly similar to those included in
the Brazilian National Health Survey (BNHS) in respect of educa-
tion across the total sample and the 5 Brazilian geopolitical regions
(Supplementary Table 1) (13). There were some minor differences
compared to the data from the BNHS by regions—in our study in the
Northeast region, there were more illiterate participants and fewer
participants with primary education, in the South region, there were
fewer illiterate participants, and in the Midwest and Southeast, there
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were less participants with a college level or above education. To
account for the differential probability of selection and differential
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nonresponse, we applied the original sample weights provided by the
ELSI-Brazil (12) before subsetting to 60 years or older participants.
Cognitive Assessment
The ELSI-Brazil cognitive function module was designed to allow a
direct comparison of the Brazilian results with the results found in
other HRS partner studies (12). The cognitive assessment includes
questions about temporal orientation (day, month, year, and day of
the week), semantic verbal fluency (the number of animal names pro-
duced within 1 minute), 10-word list test for immediate recall and
late recall, prospective memory (remember to write own name when
finishing another test), and 4 semantic memory questions (2 ques-
tions about common items, and 2 questions about political know-
ledge). The full manual with the detailed questions can be found on
the project’s homepage (http://elsi.cpqrr.fiocruz.br/).
We first created summed scores for existing subdomains (orien-
tation, fluency, episodic memory, semantic memory, and prospective
memory) and standardized the scores by subtracting the partici-
pants’ mean from the sample mean and then dividing them by the
sample standard deviation. The mean standardized z-score for all
subdomains created a global cognitive score.
Informant Interview
An informant interview was performed for participants who were
unable to complete the questionnaire (n = 161). For these partici-
pants, instead of the cognitive assessment, the Brazilian version
of 16-item Informant Questionnaire on Cognitive Decline in the
Elderly (IQCODE) was used (14,15).
Regression-Based Neuropsychological Test Norms
We first selected a normative subsample (n = 908) to provide ad-
justed regression-based norms for the cognitive assessment (16). In
the normative subsample, we included only participants without (a)
visual and hearing deficits that could affect test performance; (b)
self-report of a previous medical diagnosis of depression or clinical
depressive symptoms according to the Center for Epidemiological
Scale—Depression (cutoff of 4 points; CESD-8; (17)), (c) self-
report or informant-based diagnosis history of Alzheimer’s disease
(AD), Parkinson disease, or stroke; (d) heavy drinking based on the
National Institute of Alcohol Abuse and Alcoholism criteria (weekly
use of 14 doses or daily use of 4 doses for men, and weekly use
of 7 doses or daily use of 3 doses for women) (18); (e) self-report
or informant-based memory complaints; (f) self-report of impair-
ment in 4 gender-independent instrumental activities of daily living
(IADLs; money managing, using transportation, using the telephone,
and taking medications); and (g) missing cognitive data. Detailed
information about the number of participants excluded according
to each exclusion criterion can be seen in Supplementary Figure
1. Despite the small number of participants, the normative sub-
sample characteristics and cognitive performance were similar to the
overall sample.
We then performed a multiple regression of the standardized
global cognitive score on age, sex/gender, and education (in years),
and used the weighted coefficient values of the predictors in the
model to calculate the predicted global cognitive score for the en-
tire sample. The standardized predicted scores were then subtracted
from each participant’s actual score to calculate the residual scores.
Finally, the residual score was divided by the standard deviation
1062
of the residuals (root-mean-square error) from the normative sub-
sample multiple regression. The final z-score global cognitive score
was used to determine the presence of cognitive impairment as de-
scribed later.
Cognitive Categories
Participants were classified as either normal cognition, CIND, or
dementia based on a combination of the individual’s cognitive and
functional status, as done previously in other studies (10,16,19,20).
The algorithm included 2 major criteria for cognitive impairment:
objective cognitive performance and ability to function at usual ac-
tivities (21).
According to the regression-based norms, a z-score of −1.5 or
lower for global cognition was considered to indicate cognitive im-
pairment. In addition, we considered functional impairment if the
participant reported 1 or more difficulties in 4 gender-independent
IADLs that are associated with cognitive functioning (managing
money, using any type of transportation, using the telephone/cell-
phone, and managing/taking medication).
Participants were classified as (a) normal cognition if there were
no cognitive and functional impairments, or there was functional
impairment in the absence of cognitive impairment that was due to
physical limitations; (b) CIND if there was only cognitive impair-
ment; and (c) dementia if there were both cognitive and functional
impairments for self-respondents or an IQCODE score above the
cutoff (≥3.4) (22,23) for proxy respondents who had known the par-
ticipant for at least 2 years.
Sociodemographic and Health Conditions
We selected the following sociodemographic and health variables
to assess conditions associated with the prevalence of CIND or
dementia: age and education (measured in years), sex/gender (fe-
male or male), presence of memory complaint (if the participant
self-rated their memory or if the proxy respondent rated the
participants’ memory as fair or bad), CESD-8 total score, heavy
drinking (as described earlier), tobacco consumption history (never
smoked or current/previous use), and self-reported previous med-
ical diagnosis of diabetes. Hypertension was defined by a self-
reported previous medical diagnosis or measured blood pressure
≥140/90 mm Hg.
Statistical Analysis
We used the published and recommended mean natural and cali-
brated sampling weights to adjust for unequal probabilities of par-
ticipant selection, differential nonresponse, and complex survey
design from the ELSI-Brazil study to ensure the representative-
ness of our findings in respect of the Brazilian population (12).
Prevalence rates and 95% confidence interval (95% CI) for the cog-
nitive categories were calculated for the overall sample, stratified
by age, education, sex/gender, and a combination of sex/gender and
age. One-way ANOVA with Bonferroni correction for continuous
variables and the chi-squared test for categorical variables were
used to investigate participants’ characteristics according to cogni-
tive categories. We stratified age at 5-year intervals (60–64, 65–69,
70–74, 75–79, 80–84, 85–89, 90 years or older), and education as
illiterate, less than primary school (1–3 years), complete primary
school (4–7 years), complete middle school (8–10 years), complete
high school (11–15 years), complete college or more (≥16 years).
The prevalence CIs were calculated using a logit transform so that
the endpoints lie between 0 and 1. Projections for the Brazilian
Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6
population were performed using data from the 2010 Brazilian
National Census (24) considering sex/gender and age stratification
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for 2015, 2019, 2030, and 2050. The prevalence found for sex/
gender and age subgroups was applied to the population projections
for each stratum and summed to compute the final population pro-
jection. Finally, we built a Poisson regression model to evaluate the
association between the sociodemographic and health factors with
the cognitive categories (normal cognition as the reference group)
(25). A prevalence ratio (PR) greater than 1.0 for a continuous vari-
able suggests that when the variable value increases by 1 unit (year,
for example), the prevalence increases (CIND or dementia), whereas
a PR of less than 1.0 indicates a decrease in the prevalence when
the variable value increases by 1 unit while holding constant all
other variables in the model. For categorical variables, a PR greater
than 1.0 indicates an increased prevalence for the exposed group in
comparison to the reference group (e.g., male compared to female),
whereas a PR of less than 1.0 indicates a decreased prevalence for
the exposed group. Analyses were performed using Stata software
version 13 (26), using the svy and subpop command to take into
account the sampling weights.
Considering that the missing cases accounted for only 3% of the
eligible sample, which were impaired enough to not undergo the cog-
nitive assessment and have possible unreliable informants that were
not able to complete the IQCODE, we considered that the risk of
bias was not enough to perform a sensitivity analysis under such
condition (Supplementary Methods 1 and Supplementary Table 1).
We performed 3 sensitivity analyses to verify the algorithm clas-
sification by (1) modifying the normative subsample selection, (2)
modifying the cognitive impairment criteria, and (3) analyzing a
small sample of participants with informant report of a previous
diagnosis of AD (Supplementary Methods 2).
Results
The overall sample and group characteristics are described in
Table 1. The mean age of the sample was 70.1 (±7.8) years, with
a 4.6 (±4.4) mean years of education (75% of the sample had less
than middle school and 22% were illiterate). Women represented
60% of the sample, and almost half of the participants had memory
complaints. 4 463 participants were classified as normal cognition,
422 as CIND, and 364 as dementia (Supplementary Figure 2). The
normal cognition group was younger and had fewer depressive
symptoms than the CIND and dementia groups (Table 1).
Table 2 describes the prevalence rates for the cognitive groups
in the overall sample, stratified by age, education, and sex/gender.
We found a general prevalence of 5.8% (95% CI = 4.7–7.2) for de-
mentia and 8.1% (95% CI = 6.8–9.5) for CIND. Dementia preva-
lence ranged from 3.2% (60–64 years old) to 42.8% (≥90 years old)
by age, and from 2.1% (college level or higher) to 16.5% (illiter-
ates) by educational level. Women had a higher dementia prevalence
(6.8%) than men (4.6%). CIND prevalence was similar across the
age, sex, and education groups. Only 62 participants had a self-
report or informant-based report diagnosis of AD, representing
1.2% of the sample.
Supplementary Table 2 describes the prevalence rates for the
combination of sex/gender and age. Dementia prevalence rates were
higher among women after the seventh decade of life (Figure 1).
According to the estimated prevalence and the Brazilian population
projections, and assuming prevalence will remain the same in this
age group, we estimate 1 261 826 million cases of dementia in 2013
(population estimative used in the ELSI-Brazil), 1 479 414 million
Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6 1063

Table 1. Overall Sample Characteristics and by Cognitive Categories (n = 5 249)

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Overall (n = 5 249) Normal Cognition (n = 4 463) CIND (n = 422) Dementia (n = 364) p Value

Age* 70.1 (7.8) 69.4 (7.3) 71.48(8.1) 76.9 (9.5) <.001

Education† 4.6 (4.4) 4.8 (4.4) 4.6 (4.8) 2.0 (3.2) <.001
Educational levels (%)
Illiterate 1 132 (19.0) 829 (15.7) 113 (21.3) 190 (51.5)
Less than primary education 1 229 (23.4) 1 064 (23.3) 95 (24.0) 70 (20.2)
Primary education 1 561 (30.2) 1 382 (31.8) 106 (24.8) 73 (19.2)
Middle school 443 (9.0) 400 (9.6) 31 (8.4) 12 (3.4)
High school 592 (12.0) 532 (12.9) 49 (12.7) 11 (3.2)
≥College 287 (6.2) 254 (6.5) 28 (8.6) 5 (2.3)
Sex/gender (% female)‡ 3 144 (60.0) 2 618 (58.6) 277 (65.6) 249 (68.4) <.001
Memory complaints (%)* 2 419 (46.2) 1 966 (44.1) 216 (51.6) 237 (65.3) <.001
Global cognition§ (n = 5 088) -0.3 (1.1) -0.0 (0.8) −2.1 (0.5) −2.3 (0.6) <.001
CESD-8‡ 3.8 (1.7) 3.8 (1.7) 4.2 (1.8) 4.3 (1.9) .015
Heavy drinking (%)† 459 (8.7) 410 (9.2) 36 (8.5) 13 (3.5) .001
Never smoked (%) 2 408 (45.8) 2 042 (45.7) 198 (46.9) 168 (46.1) .894
Hypertension (%) 3 229 (61.6) 2 748 (61.7) 250 (59.4) 231 (63.6) .466
Diabetes (%)|| 999 (19.1) 819 (18.4) 93 (22.2) 87 (23.9) .008

Notes: CIND = cognitive impairment no dementia; CESD-8 = Center for Epidemiological Scale—Depression 8-item version. Group comparison: *Normal
cognition < CIND < Dementia; †Normal cognition, CIND > Dementia; ‡Normal cognition < CIND, Dementia; §Normal cognition > CIND > Dementia; ||Normal
cognition < Dementia.

Table 2. Prevalence of Normal Cognition, CIND, and Dementia (n = 5 249) for the Overall Sample, Stratified by Age, Education, and Sex/
Gender

Normal CIND Dementia

n = 4 463 n = 422 n = 364

Overall 86.0 (84.4–87.7) 8.1 (6.8–9.5) 5.8 (4.7–7.2)

Age (y)
60–64 89.5 (87.0–91.7) 7.2 (5.3–9.6) 3.2 (2.1–4.7)
65–69 89.5 (87.5–91.3) 7.6 (6.1–9.5) 2.7 (1.7–4.3)
70–74 89.2 (86.1–91.7) 6.8 (5.1–9.1) 3.9 (2.7–5.5)
75–79 81.8 (77.5–85.5) 9.3 (6.7–12.9) 8.7 (6.5–11.4)
80–84 75.5 (71.0–79.6) 11.8 (8.6–16.0) 12.6 (9.2–17.0)
85–89 66.6 (59.5–73.1) 12.0 (7.8–18.0) 21.3 (16.5–27.1)
≥90 47.2 (35.1–59.6) 10.0 (4.2–21.5) 42.8 (32.8–53.4)
Education
Illiterate 74.0 (70.4–77.2) 9.4 (7.5–11.8) 16.5 (13.2–20.4)
Less than primary education 86.5 (83.6–89.0) 8.3 (6.1–11.4) 5.1 (3.9–6.6)
Primary education 89.7 (87.8–91.3) 6.5 (5.1–8.3) 3.6 (2.8–4.7)
Middle school 90.3 (86.6–93.0) 7.4 (5.0–11.1) 2.2 (1.2–4.0)
High school 90.0 (86.4–92.8) 8.3 (5.8–11.2) 1.5 (0.8–2.8)
≥College 87.0 (81.0–91.3) 10.8 (7.0–16.3) 2.1 (0.5–7.6)
Sex/gender
Female 84.0 (81.5–86.2) 9.1 (7.4–11.0) 6.8 (5.5–8.5)
Male 88.5 (86.3–90.3) 6.8 (5.4–8.5) 4.6 (3.4–6.2)

Notes: Values represent % (95% confidence intervals). CESD-8 = Center for Epidemiological Scale—Depression 8-item version.

cases in 2015, 1 757 480 million cases in 2019, 2 780 586 million
cases by 2030, and 5 504 815 million cases by 2050.
Being older, having memory complaints, having more depres-
sive symptoms, and having hypertension were associated with an
increased greater likelihood for CIND classification (Table 3). In
addition, being older, having lower education, and having more de-
pressive symptoms were associated with increased prevalence of de-
mentia classification (Table 3).
Sensitivity analyses demonstrated that the changes in the algo-
rithm (sensitivity analyses 1 and 2) produced similar prevalence
compared to the original algorithm. Also, our algorithm was able
to classify most of the participants with informant report of AD as
having dementia (sensitivity analysis 3; Supplementary Methods 2).
Discussion
We provided prevalence rates of dementia and CIND using data
from a large and nationally representative sample of Brazilian older
adults. We found a prevalence of 5.8% for dementia and 8.1% for
CIND, which would mean that there were 1 757 480 million people
aged 60 years and older in Brazil living with dementia in 2019
and, at least, another 2 271 314 million having to deal with some
1064 Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6

Table 3. Association of Sociodemographic and Clinical Variables

With Cognitive Groups (n = 4 508)

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95% CI

PR Lower Upper p Value

CIND
Age 1.03 1.02 1.05 <.001
Sex/gender
Female 1.00
Male 0.81 0.58 1.11 .200
Education 1.03 0.98 1.08 .174
Memory complaint
No 1.00
Yes 1.45 1.12 1.88 .004
CESD-8 1.10 1.01 1.21 .028
Heavy drinking
No 1.00
Yes 1.16 0.70 1.90 .560
Never smoked
No 1.00
Yes 1.10 0.82 1.44 .527
Hypertension
No 1.00
Yes 1.33 1.05 1.68 .015
Diabetes
No 1.00
Yes 1.14 0.89 1.46 .296
Figure 1. Prevalence of cognitive impairment no dementia (CIND) and Dementia
dementia (with 95% confidence intervals) by age group and sex/gender Age 1.05 1.02 1.07 <.001
(female in red and dashed line and male in blue solid line). Sex/gender
Female 1.00
Male 0.74 0.50 1.11 .147
cognitive impairment. However, only 1.2% of the selected sample Education 0.85 0.73 0.99 .040
had a previous self-report diagnosis of dementia, highlighting the Memory complaint
underdiagnosis that is rampant in Brazil (27). Unfortunately, most No 1.00
people with dementia are diagnosed at more advanced stages of the Yes 1.32 0.92 1.91 .127
disease and miss the opportunity to benefit from available interven- CESD-8 1.11 1.03 1.20 .007
tions, as well as prepare for the future. More importantly, our pro- Heavy drinking
jections suggest that these numbers will increase fivefold over the No 1.00
Yes 0.73 0.34 1.57 .427
next 3 decades, similar to other LMICs. Socioeconomic inequalities,
Never smoked
limited resources, and lack of access to high-quality education and
No 1.00
the health systems, which are common characteristics of countries
Yes 1.30 0.87 1.95 .189
like Brazil, make this scenario even more challenging. Hypertension
Although the prevalence of dementia has been widely investi- No 1.00
gated in developed countries (1), there is still a lack of accurate in- Yes 1.33 0.96 1.85 .084
formation on the actual number of individuals living with dementia Diabetes
and cognitive problems in LMICs. In Brazil, for example, studies on No 1.00
this topic are still scarce. Four community-sample studies conducted Yes 1.14 0.72 1.81 .570
in Brazil (9,28–30) with diagnoses based on robust clinical evalu-
ation, standard criteria, and identified as having a low risk of bias, Notes: Poisson regression predicting CIND and dementia. CESD-8 = Cen-
ter for Epidemiological Scale—Depression 8-item version; CI = 95% con-
found similar estimates of dementia prevalence (varying from 5.1%
fidence interval for the prevalence ratio; CIND = cognitive impairment no
to 8.3%), and 2 of them (28,29) found higher prevalence (varying
dementia; Reference group = normal cognition; PR = prevalence ratio.
from 12.5% to 12.9%) after adjusting for the screening accuracy
with older adults aged 60 years or more. Our study is unique in
that it is the first in Brazil to estimate dementia prevalence in a na- between the estimates in our study and those in the Tremembé study
tionally representative sample using a valid and recognized method may be due to their use of a more comprehensive neuropsycho-
and found a lower rate in comparison with previous epidemiological logical battery although we used an algorithm based on the results
studies that used an extensive clinical evaluation and internation- of the few tests which were performed as part of the ELSI-Brazil
ally accepted criteria to diagnoses dementia cases conducted in the study. However, it is also important to highlight other differences.
richest Brazilian state (11). The Tremembé study had a small sample size (n = 630) and did not
César et al. (10) reported a much higher dementia prevalence use a regression-based norms approach for the cognitive measures,
(17.5%) in a Brazilian sample of older adults aged 60 and above which might have contributed to an increased rate of dementia
from Tremembé, a small town in Sao Paulo state. The difference diagnosis among the participants with low education. A previous
Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6
ELSI-Brazil machine learning analysis (31) found a lower rate of
dementia (4.7%), but analyzed participants aged 50 or older, and
used a different algorithm methodology to classify the participants.
Our study used a cognitive battery that did not evaluate several
cognitive domains, which might have contributed to an under-
estimation of dementia and CIND prevalence. Therefore, a more
complete and specific cognitive evaluation with a representative
subsample of the ELSI-Brazil should be performed, similar to those
performed in the Harmonized Cognitive Assessment Protocol in
the HRS (32), the Diagnostic Assessment of Dementia from the
Longitudinal Aging Study in India (33), and the Ancillary Study on
Cognitive Aging in Mexico from the Mexican Health and Aging
Study (MHAS) (34).
Studies that found higher rates of prevalence were usually per-
formed in samples at higher risk for dementia (in rural areas, with
lower education, and/or low socioeconomic levels) and did not
adjust for sociodemographic characteristics when selecting appro-
priate cutoffs for cognitive screening among individuals with low
education. For example, the study by Magalhães et al. (35) found a
prevalence of 49.6% in a sample of 466 older adults aged over 60
in a rural area, with more than 50% of participants being illiterate.
Furthermore, the diagnosis was based on the cognitive section of the
Cambridge Examination for Mental Disorders, using a cutoff for
dementia based on an international study, and very high for older
adults with low or no educational level (36), probably resulting in
misdiagnosis and an elevated dementia prevalence rate.
Similar dementia prevalence rates to ours have been reported for
other Latin American populations and other LMICs (3,37). For ex-
ample, crude prevalence using pooled data from 8 Latin American
studies was 7.1% for older adults aged 65 and above (38). When
comparing the age groups and stratified by age and sex/gender, we
found a similar prevalence (38). Our findings are also similar to
those found in Mexico (6.1%) using data of an HRS partner study
(MHAS) and a similar approach with the same age group (20) and
the number of estimated people aged 60 and above with dementia in
Brazil for 2019 (1.76 million) is similar to that suggested by Nichols
et al. (1) using the GBD data (1.85 million), specially if we consider
that their estimation is for those aged 40 and above.
The HRS study published by Langa et al. (39) found a prevalence
of 8.8% in Americans aged 65 and above, a higher prevalence com-
pared to that found in our study despite having a sample with higher
levels of education than ours. However, they used a different ap-
proach, with their dementia diagnosis being based on the evaluation
performed during the Aging, Demographics, and Memory Study
(ADAMS), an HRS sub-study on AD and dementia. The ADAMS
used a 4-hour in-home neuropsychological and clinical assessment
combined with expert clinician judgment to obtain a gold-standard
diagnosis of CIND or dementia. This may partially explain the
difference found on dementia prevalence between this study and
our study.
For CIND rates, we found a lower prevalence than previous
Brazilian community samples (ranging from 19.5% to 22.4%)
(10,40). Our results found that CIND prevalence is similar from 60
to 79 years old, when it increases, reaching about 12% among those
aged 80 and above. Despite finding a higher total CIND prevalence,
César et al. (10) reported no continuous increase in CIND preva-
lence with age, which is similar to our finding. The absence of a
steady increase in CIND prevalence has also been reported in other
countries (20,41,42), but this is not a common finding. Our find-
ings regarding CIND prevalence should be interpreted with caution
1065
due to the potential limitations in the algorithm classification, as
it may have resulted in an underestimation of its prevalence. Our
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participants classified as CIND had cognitive performance slightly
better than the participants classified as dementia, but both groups
revealed a mean cognitive performance below 2 standard devi-
ations of the mean. The ELSI-Brazil cognitive assessment is brief
and might not be able to capture subtle cognitive impairment,
leading some participants with CIND to be misclassified as having
normal cognition.
Although sex/gender was not associated with a higher preva-
lence of CIND and dementia, we found that general prevalence was
slightly higher for women than men, a finding commonly reported
in other epidemiological studies and summarized in the recent 2019
GBD estimates (1). The reason for the higher prevalence among
women may be a survival bias, as women usually live longer than
men in Brazil and other countries or it may be related to hormonal
changes due to menopause (24,43,44). Nevertheless, our prevalence
rates were higher for women in all age strata (except in the youngest
age range of 60–64 years), and sex differences might persist even
after survival bias adjustment (45,46). Although women do present
longer life expectancy, they face a higher burden of chronic diseases,
disability, and other age-related health conditions (e.g., frailty, sen-
sory deficits, depressive symptoms) (47) which are closely related to
the development of dementia. Additionally, socioeconomic disadvan-
tages throughout the life course put an extra burden on women as
they get older, particularly in LMICs (48,49). For example, women
have less access to education, to occupations with more cognitive
demands, and to salaries equal to those received by men. Such dis-
parities might culminate with fewer resources and cognitive reserve
in late life.
We found that the prevalence of dementia increases with age
(1,50) and decreases with higher education (51,52) as widely re-
ported in other studies. Increased age was also associated with in-
creased CIND prevalence. In contrast, increased education was
associated with dementia only. Our participants with CIND had a
similar educational level to the normal cognition group, although
the participants with dementia revealed a significantly lower level.
This suggests that the CIND group might also benefit from a higher
cognitive reserve. Considering that education is a strong predictor
of dementia prevalence and there were a few potentially important
differences in respect of education level between the ELSI-Brazil
sample and the BNHS for some of the 5 geographical regions
(Supplementary Table 1), we believe it would be a possible source of
bias to perform further analyses of dementia prevalence separately
for each region.
The presence of depressive symptoms was a factor associated
with cognitive impairment (CIND and dementia). Dementia and de-
pression can co-occur in older adults, but depression might also act
as a risk factor (53,54). Because our data are cross-sectional, we
cannot state how long depressive symptoms were present before the
participants’ inclusion in the study, and because we were only able
to assess current symptoms and not establish a formal depression
diagnosis, we decided not to exclude participants with depression
symptoms. However, we acknowledge that this is a limitation. As
we did not exclude participants with depressive symptoms from the
classification algorithm, some participants might present cognitive
impairment associated with depression and might be misclassified
as dementia.
Hypertension is a known risk factor for cognitive impairment
(55) and was related to a higher CIND prevalence in our sample.
1066
Hypertension compromises the integrity of the cerebral micro-
circulation resulting in impaired cerebral blood supply and can
promote neuroinflammation and exacerbation of amyloid path-
ologies (56).
Our study has some limitations that should be noted. First,
the use of several self-reported measures, including in respect of
identifying people with dementia. Information on daily living ac-
tivities was self-reported, which may mean that some participants
with difficulties with their daily living activities did not report
them. In addition, the cognitive screening battery used does not
assess all cognitive domains, making it more difficult to identify
participants with dementia or CIND related to visuospatial and
executive deficits. Nevertheless, our cognitive battery covers im-
portant and frequent cognitive domains that are usually com-
promised in the early stages of most dementia subtypes, such as
episodic memory and verbal fluency. Although these are limita-
tions, in the algorithm, we included 2 major criteria for cognitive
impairment (objective cognitive performance and ability to per-
form daily activities) (21). At this moment, we are not able to pro-
vide a gold-standard comparison to the algorithm classification,
but we have conducted 3 different sensitivity analyses, and all of
them reinforced our findings. Future studies with the ELSI-Brazil
follow-up data will allow further investigation of the predictive
validity of the algorithm used.
Despite these limitations, our study has strengths. This is the
first dementia and CIND epidemiology study using a large and na-
tionally representative sample of Brazil applying the HRS meth-
odology of cognitive classification, which could facilitate the
comparison of our results with other aging cohorts across the
globe. Our studies might also provide information to global ini-
tiatives about dementia prevalence and burden. The results of this
study, in addition to providing data about dementia epidemiology,
can be used to assess dementia burden and motivate public policies
related to dementia care.
In conclusion, we reported dementia and CIND rates among
Brazilian older adults and the factors related to these cognitive
groups. The continued monitoring of trends in dementia prevalence
is important to better understand the true situation in LMICs and
provide reliable evidence to inform public policies.
Supplementary Material
Supplementary data are available at The Journals of Gerontology,
Series A: Biological Sciences and Medical Sciences online.
Funding
The ELSI-Brazil baseline study was supported by the Brazilian Ministry
of Health (DECIT/SCTIE—Department of Science and Technology from
the Secretariat of Science, Technology and Strategic Inputs [grant number
404965/2012-1]; COSAPI/DAPES/SAS—Healthcare Coordination of
Elderly, Department of Strategic and Programmatic Actions from the
Secretariat of Health Care [grant numbers 20836, 22566, and 23700]);
and the Brazilian Ministry of Science, Technology, Innovation and
Communication. C.K.S., C.P.F., and M.F.L.C. are recipients of the National
Research Council (CNPq)’s research productivity fellowships. The funding
agencies had no role in the conceptualization or investigation of the study;
data curation, project administration, analysis, and interpretation of the
data; and writing, review, editing, or approval of the manuscript. The
present study was conducted using the publicly available deidentified ELSI-
Brazil data set.
Journals of Gerontology: MEDICAL SCIENCES, 2023, Vol. 78, No. 6
Conflict of Interest
Downloaded from https://academic.oup.com/biomedgerontology/article/78/6/1060/6995432 by FAMERP - FAC. DE MEDICINA DE SÃO JOSÉ DE RIO PRETO user on 13 May 2024
None declared.
Ethics Approval
This study was performed in line with the principles of the Declaration of
Helsinki. ELSI-Brazil was approved by the ethics board of the Fundação
Oswaldo Cruz (FIOCRUZ), Minas Gerais (Certificado de Apresentação para
Apreciação Ética: 34649814.3.0000.5091). Genotyping of the cohort popula-
tion was approved by Brazil’s national research ethics committee (Certificado
de Apresentação para Apreciação Ética: 63725117.9.0000.5091). Participants
signed separate informed consent forms for the interviews, physical measure-
ments, and the laboratory assays, authorized sample storages, and access to
administrative records.
Consent to Participate
Informed consent was obtained from all individual participants included in
the study.
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