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Author response: Incident parkinsonism in older adults without Parkinson disease

We thank Mahlknecht et al. for the interest in our study, which reported on risk factors for incident parkinsonism in community-dwelling older adults without Parkinson disease (PD).1 Mahlknecht et al. confirmed and extended some of our findings, growing the literature that demonstrates that PD, like other chronic diseases of aging, has a long subclinical phase in which brain pathology develops without clinical signs or symptoms, followed by mild signs and symptoms of insufficient severity to warrant a diagnosis of PD, with PD representing a late manifestation.2 Overall, this conceptual model is similar to the one currently used for Alzheimer disease (AD).3 However, parkinsonian signs are much more common than subclinical PD pathology and are associated with diverse brain pathologies.4,5 Thus, like AD dementia, the clinical phenotype of parkinsonism in older adults may be caused by diverse etiologies. A means for identifying the subset of persons with parkinsonian signs who have PD pathology and are therefore likely to be at a higher risk for progressing to PD is urgently needed.