Age-, and gender -specific incidence of vascular parkinsonism, progressive
supranuclear palsy, and parkinsonian-type multiple system atrophy in North East
Scotland: The PINE study.
Robert Caslake PhD1, Kate Taylor MD2, Neil Scott PhD3, Clare Harris MSc3, Joanna Gordon
BA3, Katie Wilde MMath3, Alison Murray PhD1, Carl Counsell MD3
1
Division of Applied Medicine
University of Aberdeen
2
Department of Neurology
Raigmore Hospital
Inverness
3
Division of Applied Health Sciences
University of Aberdeen
Corresponding author
Dr R Caslake
Tel +44(0)1224 556789
Email: bob.caslake@abdn.ac.uk
Key words: Parkinsonism, Vascular parkinsonism, Multiple system atrophy, Progressive
supranuclear palsy, Incidence
Abstract word count: 243
Article word count: 3281
Running title:
Incidence of atypical parkinsonism in Scotland
Funders:
Parkinson’s UK, Doris Hillier BMA Award, BUPA Foundation, SPRING, NHS Grampian
Endowments.
Conflicts of interest:
None declared.
1
ABSTRACT
Introduction
There have been few incidence studies of vascular parkinsonism (VP), progressive
supranuclear palsy (PSP), and parkinsonian-type multiple system atrophy (MSA-P). We
measured the age-, gender- and socioeconomic-specific incidence rates for these conditions in
north-east Scotland.
Methods
Incident non drug-induced parkinsonian patients were identified prospectively over three
years by several overlapping methods from a baseline primary care population of 311,357.
Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Patients had
yearly follow-up to improve diagnostic accuracy.
Incidence rates using the diagnosis by established research criteria at latest follow-up were
calculated for each condition by age, gender, and socioeconomic status.
Results
Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were
confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD
9.8; 61% men). The crude annual incidence was 3.2 per 100,000 (95% confidence interval
(CI) 2.2-4.3) for VP, 1.7 per 100,000 (95% CI 1.0-2.4) for PSP, and 1.4 per 100,000 (95% CI
0.8-2.1) for MSA-P. VP and MSA-P were more common in men (age-adjusted male to
female ratios 2.58 (95% CI 1.65-3.83) and 8.65 (95% CI 4.73-14.5) respectively). Incidence
did not vary with socioeconomic status.
Discussion
This is the first community-based, prospective study to report the incidence of vascular
parkinsonism and the third to report the incidence of PSP and MSA-P. Further follow-up and
comparison with similar studies in different populations will yield valuable prognostic and
aetiological information on these conditions.
2
INTRODUCTION
Knowledge of the incidence of a condition is important both in terms of planning the
allocation of healthcare resources and, when compared between populations, in identifying
potential aetiological factors. Few studies have reported the incidence of specific
parkinsonian disorders other than Parkinson’s disease (PD). To date, three studies have
reported the incidence of both parkinsonian type multiple system atrophy (MSA-P) and
progressive supranuclear palsy (PSP), one over an extended period in the USA [1] and two as
part of studies measuring the incidence of PD in Sweden [2] and Moscow [3]. The crude
incidence reported by these studies varied substantially, between 0.11 and 2.1 per 100,000
per year for MSA-P and between 0.14 and 1.1 per 100,000 per year for PSP. One further
study, which was carried out over a ten year period in Iceland, reported a crude incidence of
all MSA (including parkinsonian and cerebellar subtypes) of 0.6 per 100,000 per year.
Sixteen of the nineteen patients identified in the latter study were thought to have the
parkinsonian subtype, giving a crude incidence of MSA-P of around 0.5 per 100,000 per year
[4]. Even less is known about the incidence of vascular parkinsonism, with only two studies
having reported a figure for the general population. These studies were carried out in the
same county in the USA (Olmsted County, Minnesota), one published in 1984 [5] reported an
incidence of vascular parkinsonism of 0.25 per 100,000 per year and the other, published 15
years later, [6] of 0.07 per 100,000 per year. Two more recent studies limited to people aged
over 65 years have reported much higher incidences in this older age group of 23.6 per
100,000 per year [7] and 65.8 per 100,000 per year [8].
Follow-up is required to improve the accuracy of the diagnosis of parkinsonian syndromes,
which may be poor in the early stages of the condition [9,10] and to provide the most
accurate and representative data on prognosis. Ideally, this follow-up would be carried out
prospectively by movement disorder experts as part of the incidence study in order to ensure
accuracy and consistency. However, in only one of the above studies [2] was the diagnosis
informed by a study specific period of prospective follow-up (only one year), whilst in two
retrospective studies there was a period of routine clinical follow-up from case records [1,4].
We undertook a large prospective, community-based incidence study of degenerative and
vascular parkinsonian conditions with planned long-term follow-up of the incident cohort and
here report the age-, gender-, and socioeconomic status- specific incidence figures for MSAP, PSP, and vascular parkinsonism.
3
METHODS
The Parkinsonism Incidence in North-East Scotland (PINE) study [11] attempted to identify
all incident patients with degenerative or vascular parkinsonism in a well-defined population
in and around Aberdeen, UK. This was done in two phases: a pilot phase in 148,600 people
registered with 18 general (primary care) practices over 18 months from November 2002 and
the main phase extended to 317,357 people from all 37 general practices in the area over 36
months from April 2006 (Figure S1). Everyone in the population should be registered with
one practice. Secondary care for this population was provided by one general hospital, one
psychiatric hospital, and one hospital providing medicine for the elderly. Detailed methods
have been reported previously [11,12] and so will only be summarized here.
The study was carried out in two steps: identification of all people in the baseline population
developing neurodegenerative or vascular parkinsonism within the incident period (incident
cases); and determination of the likely cause of parkinsonism in those patients.
Identification of people with parkinsonism
Case finding
Potential incident cases were identified by: (i) direct referrals to the study of anyone with
suspected new onset parkinsonism from general practitioners (all of whom had the study
criteria and goals explained to them in a visit by one of the authors in the 6 months prior to
the start of the study) and NHS or private hospital specialists (neurology, medicine for the
elderly, old age psychiatry, general medicine); to avoid missing cases, clinicians were sent
regular email reminders during the study and encouraged to have a low threshold for referral,
even if they felt that an alternative diagnosis was a possibility; (ii) weekly hand searching of
outpatient referral letters to neurology and medicine for the elderly to identify any related to
possible parkinsonism; again we used a low threshold to select those who were offered
assessment as part of the study; (iii) electronic searching of general practice databases at
baseline and annually to identify patients who had been given diagnostic codes for
parkinsonism or tremor or were prescribed anti-parkinsonian medications without a clear
alternative explanation (e.g. dopamine agonists prescribed for restless legs syndrome or for
endocrine disorders); (iv) electronic searching of hospital discharge data every three months
4
from the general and geriatric hospitals for patients with a parkinsonian diagnosis; (v)
questionnaire-based population screening (only during the pilot study) as previously reported
[13,14].
Baseline assessment
All patients identified as potential incident cases were invited to undergo clinical assessment
by a neurologist with an interest in PD (CC) or a supervised trainee (RC, KT) either in clinic,
their home if unable to attend a clinic, or the hospital ward if they were identified during a
hospital stay. This assessment included a standardised history and examination, including the
motor subsection (Part 3) of the Unified Parkinson’s Disease Rating Scale [15] (UPDRS),
which was video-recorded and reviewed by two study doctors, and specific clinical
assessment of features atypical for idiopathic PD including lying and standing BP, eye
movements, cerebellar and pyramidal tract testing and assessment of cortical signs including
inattention and apraxia.
Radiological imaging using structural MRI and/or 123I ioflupane single photon emission
computed tomography (FP-CIT SPECT) was only performed if deemed clinically necessary.
For potential incident patients who could not be assessed, for whatever reason, a consensus
decision regarding their eligibility was made using the available information. If there was
uncertainty about whether a patient met the inclusion or exclusion criteria, they were
reviewed in six or 12 months and, if the uncertainty remained, they were included as incident
patients for follow-up.
Inclusion criteria
Patients were included as incident cases if both the following criteria were met:
1) Presence of parkinsonism defined by two or more of the four cardinal motor features (rest
tremor, bradykinesia, rigidity, and postural instability with no other medical cause) or the
presence of an isolated asymmetric rest tremor (because some patients go on to develop other
features of parkinsonism if followed up long-term) [16].
2) First diagnostic suspicion of parkinsonism occurred within the incident period and while
the patient was registered with a participating general practice.
5
Exclusion criteria
Patients were excluded if their parkinsonism was thought to be drug-induced i.e. when the
parkinsonism resolved within six to 12 months of stopping the responsible drug or, if the drug
could not be stopped, when FP-CIT SPECT was normal. Where FP-CIT SPECT was not used
and the drug could not be withdrawn, the patient was excluded.
Determination of cause of parkinsonism
Assessment, Diagnosis, and Follow-up
Incident patients could give formal, written consent to any or all of the following: annual
review of their medical records; long-term survival follow-up through the UK central death
register; yearly full study assessments including the full UPDRS and assessments of
disability, quality of life, cognition (mini-mental state examination (MMSE) [17] and minimental Parkinson (MMP)[18]) and mood [11]. Those who did not consent to any part were
still offered usual clinical follow-up. Follow-up in both phases of the study is planned to be
lifelong. At each assessment up to three possible diagnoses were listed based on clinical
judgement using all available information and after discussion between the study neurologist
and the supervised trainee. These were listed in order of probability with a percentage
likelihood, again based on the judgement of the assessing doctor. Patients who started
treatment were seen after four months to assess subjective and objective response. The issue
of post-mortem examination to clarify the diagnosis was discussed with most participants
during follow-up. All diagnoses made without post-mortem confirmation were considered
probable rather than definite.
Diagnosis of MSA-P and PSP was made in accordance with established diagnostic criteria
[19,20] and categorized as definite, probable or possible according to those criteria. An age at
onset of over 75 was not considered sufficient for exclusion of the diagnosis of MSA-P. No
such established criteria for vascular parkinsonism were found, though criteria were proposed
by Zijlmans et al in 2004 [21] and these were used to inform the diagnosis. Vascular
parkinsonism was considered definite if confirmed by post-mortem, probable where there
was insidious onset parkinsonism predominantly affecting the lower body with imaging
evidence of extensive subcortical white matter ischaemia, or where there was rapid onset of
hemiparkinsonism with a contralateral infarct in an appropriate area. The diagnosis was
considered possible if no imaging was obtained, but where insidious onset parkinsonism
6
primarily affecting the lower body was presentin combination with significant vascular risk
factors and/or a history of cerebrovascular disease. A good, sustained response to
dopaminergic therapy (especially with the development of motor fluctuations or dyskinesias)
was considered to exclude the diagnosis. Diagnosis was also excluded if criteria for another
parkinsonian syndrome were met.
Given the change in diagnosis that can occur with follow-up [10], the latest clinical diagnosis
was used for calculation of incidence figures (data extracted in December 2010, 21 months
after the end of recruitment).
Baseline population data
Baseline population data were obtained from NHS Practitioner Services, broken down by
practice, age, gender and the Carstairs and Morris Index of Deprivation [22] (DepCat), a
small area postcode measure of socioeconomic status, based on the 2001 Scottish census.[23]
Average populations throughout the incidence periods were estimated by taking the mean of
the populations at the start and end of those periods.
Statistical analysis
Statistical analyses were carried out using PASW 18.0. Normally distributed data were
compared using an unpaired Student’s t-test (no paired data were compared) or analysis of
variance, as appropriate, non-parametric scale variables were compared using the MannWhitney U-test or the Kruskal Wallis test, and proportions were compared using the χ2 test or
Fisher’s exact test as appropriate. Age-adjusted male to female (M:F) incidence ratios were
calculated by applying age-specific female incidence rates to the corresponding male
population, then calculating a ratio. Confidence intervals were calculated using Confidence
Interval Analysis (CIA) version 1.0.
Role of funding source
Funders approved and made suggestions regarding the study protocol, but had no role in
collection or analysis of data, or in the production of this report.
Ethics
7
Permission for this study was given by the Local Research Ethics Committee. Permission for
sections dealing with people with dementia was given by the Scottish Multi-Centre Research
Ethics Committee.
RESULTS
The study profile is shown in Figure 1. Out of 828 potentially incident patients assessed, 697
(mean age 72.0 (standard deviation (SD) 10.4), 41% of whom became incident patients) were
assessed in the study outpatient clinic, 41 (mean age 81.0 (SD 7.7), 61% of whom became
incident patients) were assessed at home or in their nursing home and a further 72 (mean age
79.0 (SD 9.2); 65% became incident patients) were initially assessed as hospital inpatients.
All but eighteen patients (2% of those identified) were assessed in person by a study doctor.
Four died before assessment, one moved away before assessment and the remainder did not
wish to be assessed. In five of these, enough information was available from medical records
to enable inclusion as incident patients. The rest were excluded.
Three hundred and sixty three incident patients with possible or probable parkinsonism were
identified, with a median duration of self reported symptoms of 13 months prior to initial
assessment (IQ 9 to 25). After a median follow-up of 26 months (interquartile range (IQ) 18
to 39; range 0 to 96) 38 were classified as having vascular parkinsonism, 20 PSP, and 17
MSA-P. Two other patients were diagnosed with corticobasal degeneration (both female,
ages 63 and 72) and were not included in this analysis. Baseline characteristics of the
included patients are given in Table 1. Even at baseline, many patients were not independent
in activities of daily living and those with a diagnosis of PSP were more dependent (median
Schwab and England 45 compared with 80 in MSA and 60 in vascular parkinsonism;
p=0.03). The MMP cognitive scores were lower in people with PSP and vascular
parkinsonism compared with MSA (p=0.03).
Of the 14 patients who were not felt to have parkinsonism on follow up, eight were diagnosed
with a non-parkinsonian tremor (3 essential tremor, 3 functional tremor, 1 midbrain tremor, 1
alcohol related), three were diagnosed with an isolated gait disorder of vascular origin, one
was diagnosed with drug-induced parkinsonism, one with motor neurone disease, and one
with a hemiparesis of uncertain aetiology.The incidence of these conditions by age and
gender is shown in table 2. The crude annual incidence in those aged 65 and over (calculated
8
for the purposes of comparison with other studies) was 12.2 (95% CI 6.9 to 17.5) per 100,000
for PSP, 8.5 (95% CI 4.1 to 13.0) per 100,000 for MSA-P, and 21.9 (95% CI 14.8 to 29.1)
per 100,000 for vascular parkinsonism. It should be noted that the number of patients with
each diagnosis differs slightly from those given in previous reports of the same cohort, as
research diagnostic criteria were applied herebut not in previous reports[11].
Of the 75 patients diagnosed with PSP, MSA-P or vascular parkinsonism, 50 (67%)
underwent structural brain imaging (68% magnetic resonance imaging) as part of their
assessment. Sixteen (21%) underwent FP-CIT SPECT, and eight (11%) underwent post
mortem examination. No patients underwent cardiac metaiodobenzylguanidine scintigraphy
or sphincter electromyography.
Of those diagnosed with vascular parkinsonism, 31 (82%) underwent structural imaging
(61% MRI) which confirmed infarcts in the basal ganglia or their projections or extensive
periventricular ischaemia. The remaining seven either declined scan or were deemed too frail
or unwell for scanning to be clinically appropriate. All these had predominantly lower body
parkinsonism with either a history of ischaemic stroke or two or more significant vascular
risk factors.
Age-adjusted male to female ratios were 2.58 (95% CI 1.65-3.83) for vascular parkinsonism,
1.49 (95% CI 0.71-2.73 for PSP, and 8.65 (95% CI 4.73-14.5) for MSA-P. The numbers in
each deprivation category for each disease were too small to do a formal statistical analysis
but there was no evidence of a clear variation/trend in incidence by socio-economic status for
any of the conditions (Table 3), with significant overlapping of all the confidence intervals.
9
DISCUSSION
This study found the crude incidence in the North East of Scotland of clinically diagnosed
vascular parkinsonism, PSP, and MSA-P to be 3.2, 1.7, and 1.4 per 100,000 per year
respectively. Incidence of all three disorders increased with age, the MSA-P and vascular
parkinsonism peaking in the ninth decade but PSP continuing to rise. MSA-P and vascular
parkinsonism were more common in men. None of the conditions were more common with
either high or low socioeconomic status but, given the small numbers of patients, a true
association may have been missed. There are no previous data on whether the incidence of
MSA, PSP and vascular parkinsonism vary by socioeconomic group. It might have been
expected that the incidence of vascular parkinsonism would vary with socioeconomic group
in the same way as other forms of vascular disease.
As noted previously, there has been substantial heterogeneity in the reported incidence of
vascular parkinsonism between studies in the past. The two previous studies carried out in
the whole population [5,6] report very low incidence compared with this study. An important
difference between studies appears to have been the definition used for vascular
parkinsonism. In one of the two previous studies that looked at the over 65s, the incidence of
vascular parkinsonism reported here is comparable when comparing similar age groups, [7].
The second of these studies [8] reported a higher incidence. This may have been due in part
to the more intensive case finding strategy and the much smaller baseline population size in
that study. The current study has the advantage of reporting an incidence for the whole
population rather than an age-restricted group, as well as age-stratified values, and has a
population base of roughly 100 times that of either of these restricted studies. The lack of
any previously agreed diagnostic criteria for vascular parkinsonism means that it is difficult
to compare different studies. There is a clear need for a consensus agreement on how this
condition should be identified for further epidemiological work to be carried out. We would
suggest that the criteria used here may form a reasonable starting point for discussion.
Two of the previous studies reporting the incidence of PSP in Olmsted County, Minnesota [1]
and in northern Sweden [2] reported figures similar to but slightly lower than those given
here: 1.1 per 100,000 per year in both cases. The third study reported a much lower incidence
of 0.14 per 100,000 per year in Moscow [3]. It is possible that difficulties in complete
ascertainment from the larger baseline population in the Moscow study (1,237,900 compared
with 317,357 in this study, 141,950 in the Swedish study and around 46,000 in the US study)
10
meant that cases were missed. There was a greater spread in the reported incidence of MSAP in the studies, with 0.11 per 100,000 per year reported in Moscow, 0.6 per 100,000 per year
in Olmsted County, and 2.1 per 100,000 per year in Sweden. The incidence reported here lies
roughly half way between the higher two values.
It is important to note that comparison of crude incidence rates between populations can be
affected by differing age and gender distributions between thos populations and that this may
also explain some of the apparent differences.
The main strength of this study is that recruitment was community-based, with multiple
search strategies used to prospectively identify cases. This should mean that few patients
were missed and that the patients identified are representative of all those suffering from
these conditions and not merely those attending specialist clinics. In addition, the diagnosis
used for incidence in this study was made after about two years of clinical follow-up, which
is likely to have improved diagnostic accuracy compared with studies using diagnosis at
presentation, though further follow-up will be useful and is ongoing. It is important to
acknowledge that diagnosis may continue to evolve over time and that any clinical diagnosis
of the cause of parkinsonism will be subject to error. An ideal incidence study would include
post-mortem histopathological diagnosis in all cases: only 11% (8/75) had pathological
confirmation in this study although hopefully this will increase with further follow-up. A
further strength is that those who were not able to travel to the study clinic were visited in
their home, nursing home, or in hospital. This will have gone some way toward reducing the
number of severely disabled or frail elderly patients who would have been missed by a clinic
only strategy. The relatively high proportion of patients seen in non-clinic settings who were
felt to have incident parkinsonism serves to highlight the need to include then in incidence
studies.
This is the first community-based prospective study to report the incidence of vascular
parkinsonism and the fourth to report the incidence of PSP and MSA-P. Ongoing follow-up
of this cohort will provide increased diagnostic certainty and unique, unbiased information on
the prognosis of these conditions. Comparison with similar studies in other populations,
particularly in Asia, Africa and South America, may provide helpful clues as to the aetiology
of these conditions. The development of formal evidence-based consensus criteria for the
diagnosis of vascular parkinsonism will be essential to enable further research.
11
Acknowledgements
We thank our funders (Parkinson’s UK, Doris Hillier BMA Award, the BUPA Foundation,
SPRING, NHS Grampian Endowments), Susan Kilpatrick for secretarial support, and all the
patients and general practices that took part.
Author contributions
R Caslake performed the literature search, recruited participants and collected data, analyzed
data and wrote the first draft of the paper.
K Taylor recruited patients and collected data.
N Scott provided statistical support.
J Gordon and C Harris recruited participants and collected data and performed electronic
database searching.
K Wilde provided IT and data management support.
A Murray provided diagnostic radiology support.
C Counsell conceived of and designed the study, recruited participants and collected data.
Provided input into data analysis and all drafts of paper.
All authors provided input into the final draft of the paper.
Conflicts of interest
None declared.
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Legends and footnotes
Figure 1: Study profile.
IQ: interquartile range; GP: General Practitioner; SD: Standard deviation.
Table 1 Baseline Demographics and Clinical Characteristics
*Institutionalisation defined as home address at baseline listed as residential home, nursing
home or hospital. †Data available for 36 patients. ††Data available for 37 patients. MMSE =
mini-mental state examination, MMP = mini-mental parkinson, GDS-15 = Geriatric
depression scale 15 item version.
Table 2 Age and gender specific incidence rates of vascular parkinsonism, progressive
supranuclear palsy and parkinsonian-type multiple system atrophy.
Table 3 DepCat specific incidence rates of vascular parkinsonism, progressive supranuclear
palsy and parkinsonian-type multiple system atrophy adjusted by age and gender.
DepCat= Carstairs and Morris Index of Deprivation
15
Table 1 Baseline Demographics and Clinical Characteristics
Progressive
supranuclear
palsy
n=20
Mean age (SD)
Male
DepCat 1 to 3
Symptom
Tremor
at baseline Slowness
assessment Gait
disturbance
Balance
problems
Institutionalised*
Median motor UPDRS (IQ)
78.5 (8.5)
10 (50%)
13 (65%)
9 (45%)
12 (60%)
20 (100%)
Parkinsonian
type Multiple
System
Atrophy
n=17
76.9 (10.6)
14 (82%)
11 (65%)
5 (29%)
8 (47%)
16 (94%)
20 (100%)
11 (65%)
26 (68%)†
p=0.01
5 (25%)
41 (22-48)
1 (6%)
31 (22-36)
p=0.18
p=0.46
Median Hoehn & Yahr stage
(IQ)
Median Schwab & England
score (IQ)
Median MMSE (IQ)
4.0 (2.75-5)
3.0 (2.5-3.0)
4 (11%)
29 (21-44)
[n=37]
3 (2.5-4)
45 (25-80)
80 (60-90)
60 (30-80)
p=0.03
25 (24-27)
[n=17]
25 (21-29)
[n=12]
8 (5-9)
[n=12]
4/11/5
27 (23-29)
[n=16]
29 (26-31)
[n=10]
6 (3-10)
[n=12]
0/14/3
25 (19-28)
[n=26]
23 (19-27)
[n=19]
6 (4-8)
[n=19]
4/27/7
p=0.30
Median MMP (IQ)
Median GDS-15 (IQ)
Diagnostic certainty
(definite/ probable/ possible)
Vascular
parkinsonism
n=38
78.2 (7.9)
24 (63%)
20 (53%)
17 (45%)†
27 (71%)†
33 (87%)††
p=0.84
p=0.12
P=0.56
p=0.53
p=0.23
p=0.20
p=0.12
p=0.03
p=0.67
*Institutionalisation defined as home address at baseline listed as residential home, nursing
home or hospital. †Data available for 36 patients. ††Data available for 37 patients. MMSE =
mini-mental state examination, MMP = mini-mental parkinson, GDS-15 = Geriatric
depression scale 15 item version.
16
Table 2 Age and gender specific incidence rates of vascular parkinsonism, progressive
supranuclear palsy and parkinsonian-type multiple system atrophy.
Vascular
parkinsonism
Male
0-39
40-49
50-59
60-69
70-79
80-89
90+
All
ages
Female
0-39
40-49
50-59
60-69
70-79
80-89
90+
All
ages
All
0-39
40-49
50-59
60-69
70-79
80-89
90+
All
ages
Progressive supranuclear
palsy
Multiple system
atrophy*
Person
years in
study
population
No.
of
cases
Incidence/
100,000/yr
(95% CI)
No.
of
cases
Incidence/
100,000/yr
(95% CI)
No.
of
cases
Incidence/
100,000/yr
(95% CI)
322891.5
93418.5
78492
50964
32673
12675
1276.5
0
0
0
2
11
10
1
0.0
0.0
0.0
3.9
33.7
78.9
78.3
0
0
1
0
5
2
2
0.0
0.0
1.3
0.0
15.8
15.8
156.7
0
0
2
1
4
6
1
0.0
0.0
2.5
2.0
12.2
47.3
78.3
592390.5
24
4.1
10
1.7
14
2.4
303262.5
85042.5
72216
53293.5
42480
23499
4368
0
0
2
0
4
7
1
0.0
0.0
2.8
0.0
9.4
29.8
22.9
0
0
0
1
4
5
0
0.0
0.0
0.0
1.9
9.4
21.3
0.0
0
0
0
0
0
3
0
0.0
0.0
0.0
0.0
0.0
12.8
0.0
584161.5
14
2.4
10
1.7
3
0.5
626154
178461
150708
104257.5
75153
36174
5644.5
0
0
2
2
15
17
2
0
0
1
1
9
7
2
38
0.0
0.0
0.7
1.0
12.0
19.4
35.4
1.7
(1.0-2.4)
0
0
2
1
4
9
1
1176552
0.0
0.0
1.3
1.9
20.0
47.0
35.4
3.2
(2.2-4.3)
0.0
0.0
1.3
1.0
5.3
24.9
17.7
1.4
(0.8-2.1)
20
17
*Parkinsonian subtype only; 95% CI- 95% Confidence interval
17
Table 3 DepCat specific incidence rates of vascular parkinsonism, progressive supranuclear
palsy and parkinsonian-type multiple system atrophy adjusted by age and gender.
DepCat
(Population in person
years)
1
(302,214)
2
(291,555)
3
(136,185)
4
(224,249)
5
(85,692)
6
(136,560)
Age- and sex-adjusted annual incidence per 100,000 population
(95% CI)
Progressive
Parkinsonian type
Vascular
supranuclear palsy
Multiple System
parkinsonism
Atrophy
1.75 (0.26-3.24)
1.33 (0.03-2.64)
2.17 (0.51-3.83)
(n=6)
(n=5)
(n=7)
1.75 (0.23-3.26)
1.56 (0.12-3.00)
2.01 (0.39-3.64)
(n=5)
(n=5)
(n=6)
1.38 (-0.59-3.36)
0.50 (-0.69-1.69)
4.10 (0.70-7.51)
(n=2)
(n=1)
(n=7)
1.24 (-0.22-2.70)
0.31 (-0.42-1.05)
5.43 (2.38-8.48)
(n=3)
(n=1)
(n=14)
2.13 (-0.96-5.21)
1.83 (-1.03-4.69)
1.01 (-1.12-3.16)
(n=2)
(n=2)
(n=1)
1.61 (-0.52-3.74)
2.61 (-0.10-5.33)
2.45 (-0.17-5.08)
(n=2)
(n=3)
(n=3)
DepCat= Carstairs and Morris Index of Deprivation
18
Figure 1:
19