Objective: The aim of this study was to examine the clinical picture of Parkinson’s disease (PD) and vascular parkinsonism (VP) in the elderly, in an attempt to differentiate the clinical history, symptoms, signs and response to therapy. Material and methods: Thirty-two elderly patients with late onset PD and 45 with VP were enrolled and the clinical features of two groups were compared. All patients underwent brain MRI and were scored using the Unified Parkinson’s Disease Rating Scales (UPDRS) -II, -III. Results: Patients with PD had a younger age at onset and a longer duration of the disease as compared to patients with VP. Nearly all PD patients showed a good response to levodopa therapy, while only 29%of patients with VP were responsive to levodopa treatment. Vascular risk factors as well as postural tremor, gait disorders and pyramidal signs with lower body predominance, were more frequent in patients with VP. Ninety-three %of PD patients had normal MRI, whereas all patients with VP had cerebral vascular lesions. UPDRS-II, -III scores at baseline were higher in VP than in PD patients and their increases throughout the follow-up period were more marked in VP than in PD patients. Conclusions: Clinical history, symptoms, signs, response to therapy, and brain imaging help to differentiate PD and VP as two clinical entities with different clinical, prognostic and therapeutic implications, even if the coexistence of PD and a cerebral vascular disease in elderly patients is not infrequent and can make the diagnosis difficult. Objective: The aim of this study was to examine the clinical picture of Parkinson’s disease (PD) and vascular parkinsonism (VP) in the elderly, in an attempt to differentiate the clinical history, symptoms, signs and response to therapy. Thirty-two elderly patients with late onset PD and 45 with VP were enrolled and the clinical features of two groups were compared. All patients underwent brain MRI and were scored using the Unified Parkinson’s Disease Rating Scales (UPDRS) -II, -III. : Patients with PD had a younger age at onset and longer duration of the disease as compared to patients with VP. Nearly all PD patients showed a good response to levodopa therapy, while only 29% of patients with VP were responsive to levodopa treatment. Vascular risk factors as well as postural tremor, gait disorders and pyramidal signs with lower body predominance, were more frequent in patients with VP. Ninety-three% of PD patients had normal MRI, but all patients with VP had cerebral vascular lesions. UPDRS-II, -III scores at baseline were higher in VP than in PD patients and their increase throughout the follow-up period were more marked in VP than in PD patients. Conclusions: Clinical history, symptoms, signs , response to therapy, and brain imaging help to differentiate PD and VP as two clinical entities with different clinical, prognostic and therapeutic implications, even if the coexistence of PD and a cerebral vascular disease in elderly patients is not infrequent and can make the installation difficult .