<i>Background/Aims:</i> Older people are over-represented in pedestrian fatalities, and it has been suggested that the presence of cognitive impairment or dementia in these individuals may contribute to their accidents. Using neuropathological methods, we aimed to compare the prevalence of dementia pathology in fatally injured older pedestrians with similarly aged ambulatory subjects who died from other causes. <i>Methods:</i> The brains of 52 pedestrians (65–93 years) and 52 controls (65–92 years) were assessed for neurofibrillary tangles (NFT), neuritic plaques, Lewy bodies and vascular lesions using established neuropathological criteria. <i>Results:</i> The examination for Alzheimer’s disease (AD) pathology showed that 43% of the pedestrians had NFT scores of III–VI using Braak and Braak staging, compared with 23% of the controls (p < 0.05, Fisher’s exact test), indicating incipient, possible or probable AD. There were no differences in the prevalence of pathology for vascular dementia or dementia with Lewy bodies. <i>Conclusion:</i> These results suggest that cognitive decline associated with AD, even in the earliest stages of the disease, may be a factor in fatal traffic accidents for older pedestrians. Special measures for pedestrian safety are necessary in areas with high densities of older citizens and especially for those diagnosed as having a mild cognitive impairment or AD.