Research Article| Volume 54, ISSUE 2, P164-172, February 2018

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Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults

Published:December 12, 2017DOI:


      This is a nationally representative study of rural−urban disparities in the prevalence of probable dementia and cognitive impairment without dementia (CIND).


      Data on non-institutionalized U.S. adults from the 2000 (n=16,386) and 2010 (n=16,311) cross-sections of the Health and Retirement Study were linked to respective Census assessments of the urban composition of residential census tracts. Relative risk ratios (RRR) for rural−urban differentials in dementia and CIND respective to normal cognitive status were assessed using multinomial logistic regression. Analyses were conducted in 2016.


      Unadjusted prevalence of dementia and CIND in rural and urban tracts converged so that rural disadvantages in the relative risk of dementia (RRR=1.42, 95% CI=1.10, 1.83) and CIND (RRR=1.35, 95% CI=1.13, 1.61) in 2000 no longer reached statistical significance in 2010. Adjustment for the strong protective role of educational attainment reduced rural disadvantages in 2000 to statistical nonsignificance, whereas adjustment for race/ethnicity resulted in a statistically significant increase in RRRs in 2010. Full adjustment for sociodemographic and health factors revealed persisting rural disadvantages for dementia and CIND in both periods with RRR in 2010 for dementia of 1.79 (95% CI=1.31, 2.43) and for CIND of 1.38 (95% CI=1.14, 1.68).


      Larger gains in rural adults’ cognitive functioning between 2000 and 2010 that are linked with increased educational attainment demonstrate long-term public health benefits of investment in secondary education. Persistent disadvantages in cognitive functioning among rural adults compared with sociodemographically similar urban peers highlight the importance of public health planning for more rapidly aging rural communities.
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        • Eberhardt M.S.
        • Ingram D.D.
        • Makuc D.M.
        • et al.
        Urban and Rural Health Chartbook. Health, United States, 2001.
        Center for Health Statistics, Hyattsville, MD2001
        • Hartley D.
        Rural health disparities, population health, and rural culture.
        Am J Public Health. 2004; 94: 1675-1678
      1. U.S. DHHS. National plan to address Alzheimer’s disease: 2016 update. Published 2016. Accessed March 27, 2017.

        • Hurd M.D.
        • Martorell P.
        • Delavande A.
        • Mullen K.J.
        • Langa K.M.
        Monetary costs of dementia in the United States.
        N Engl J Med. 2013; 368: 1326-1334
        • Glasgow N.
        • Brown D.L.
        Rural ageing in the United States: trends and contexts.
        J Rural Stud. 2012; 28: 422-431
        • Bolin J.N.
        • Bellamy G.R.
        • Ferdinand A.O.
        • et al.
        Rural Healthy People 2020: new decade, same challenges.
        J Rural Health. 2015; 31: 326-333
        • Harris J.K.
        • Beatty K.
        • Leider J.P.
        • Knudson A.
        • Anderson B.L.
        • Meit M.
        The double disparity facing rural local health departments.
        Annu Rev Public Health. 2016; 37: 167-184
        • Abner E.L.
        • Jicha G.A.
        • Christian W.J.
        • Schreurs B.G.
        Rural-urban differences in Alzheimer’s disease and related disorders diagnostic prevalence in Kentucky and West Virginia.
        J Rural Health. 2016; 32: 314-320
      2. Wen M, Fan JX, Kowaleski-Jones L, Wan N. Rural−urban disparities in obesity prevalence among working age adults in the United States. Am J Health Promot. In press. Online February 1, 2017.

        • Singh G.K.
        • Siahpush M.
        Widening rural-urban disparities in life expectancy, U.S., 1969–2009.
        Am J Prev Med. 2014; 46: e19-e29
        • Vogelsang E.M.
        Older adult social participation and its relationship with health: rural-urban differences.
        Health Place. 2016; 42: 111-119
        • Zeng D.
        • You W.
        • Mills B.
        • Alwang J.
        • Royster M.
        • Anson-Dwamena R.
        A closer look at the rural-urban health disparities: insights from four major diseases in the Commonwealth of Virginia.
        Soc Sci Med. 2015; 140: 62-68
        • Langa K.M.
        • Larson E.B.
        • Crimmins E.M.
        • et al.
        A comparison of the prevalence of dementia in the United States in 2000 and 2012.
        JAMA Intern Med. 2017; 177: 51-58
        • Langa K.M.
        • Larson E.B.
        • Karlawish J.H.
        • et al.
        Trends in the prevalence and mortality of cognitive impairment in the United States: is there evidence of a compression of cognitive morbidity?.
        Alzheimers Dement. 2008; 4: 134-144
        • Stern Y.
        Cognitive reserve and Alzheimer disease.
        Alzheimer Dis Assoc Disord. 2006; 20: 112-117
        • Goldin C.
        America’s graduation from high school: the evolution and spread of secondary schooling in the twentieth century.
        J Econ Hist. 1998; 58: 345-374
      3. U.S. Department of Agriculture, Economic Research Service. Rural America at a glance. Economic Brief Number 26. Published 2014. Accessed March 27, 2017.

      4. U.S. Department of Agriculture, Economic Research Service. Rural education. Published 2016. Accessed March 27, 2017.

        • Keefover R.W.
        • Rankin E.D.
        • Keyl P.M.
        • Wells J.C.
        • Martin J.
        • Shaw J.
        Dementing illnesses in rural populations: the need for research and challenges confronting investigators.
        J Rural Health. 1996; 12: 178-187
        • Cassarino M.
        • Setti A.
        Environment as ‘brain training’: a review of geographical and physical environmental influences on cognitive ageing.
        Ageing Res Rev. 2015; 23: 167-182
        • Russ T.C.
        • Batty G.D.
        • Hearnshaw G.F.
        • Fenton C.
        • Starr J.M.
        Geographical variation in dementia: systematic review with meta-analysis.
        Int J Epidemiol. 2012; 41: 1012-1032
        • Mattos M.K.
        • Snitz B.E.
        • Lingler J.H.
        • Burke L.E.
        • Novosel L.M.
        • Sereika S.M.
        Older rural- and urban-dwelling Appalachian adults with mild cognitive impairment.
        J Rural Health. 2017; 33: 208-216
        • Hauser R.M.
        • Willis R.J.
        Survey design and methodology in the health and retirement study and the Wisconsin longitudinal study.
        Popul Dev Rev. 2004; 30: 209-235
      5. Health and Retirement Survey (HRS). Sample sizes and response rates. Published 2011. Accessed March 28, 2017.

        • Crimmins E.M.
        • Kim J.K.
        • Langa K.M.
        • Weir D.R.
        Assessment of cognition using surveys and neuropsychological assessment: the Health and Retirement Study and the Aging, Demographics, and Memory Study.
        J Gerontol B Psychol Sci Soc Sci. 2011; 66: i162-i171
      6. Ratcliffe M, Burd C, Holder K, Fields A. Defining rural at the U.S. Census. ACSGEO-1. Washington, DC: U.S. Census Bureau. Published 2016. Accessed March 27, 2017.

      7. U.S. Bureau of Labor Statistics. Updated CPI-U-RS, all items, 1977–2015. Published 2016. Accessed March 27, 2017.

        • Lichter D.T.
        • Ziliak J.P.
        The rural-urban interface: new patterns of spatial interdependence and inequality in America.
        Ann Am Acad Pol Soc Sci. 2017; 672: 6-25
        • Sheffield K.M.
        • Peek M.K.
        Changes in the prevalence of cognitive impairment among older Americans, 1993–2004: overall trends and differences by race/ethnicity.
        Am J Epidemiol. 2011; 174: 274-283
        • Peterson L.E.
        • Bazemore A.
        • Bragg E.J.
        • Xierali I.
        • Warshaw G.A.
        Rural-urban distribution of the U.S. geriatrics physician workforce.
        J Am Geriatr Soc. 2011; 59: 699-703
        • National Academy of Medicine
        Retooling for an Aging America: Building the Health Care Workforce.
        National Academies Press, Washington, DC2008
        • Kuiper J.S.
        • Zuidersma M.
        • Voshaar R.C.O.
        • et al.
        Social relationships and risk of dementia: a systematic review and meta-analysis of longitudinal cohort studies.
        Ageing Res Rev. 2015; 22: 39-57
        • Glasgow N.
        Rural/urban patterns of aging and caregiving in the United States.
        J Fam Issues. 2000; 21: 611-631
        • Baernholdt M.
        • Yan G.F.
        • Hinton I.
        • Rose K.
        • Mattos M.
        Quality of life in rural and urban adults 65 years and older: findings from the National Health and Nutrition Examination Survey.
        J Rural Health. 2012; 28: 339-347
        • Hall S.A.
        • Kaufman J.S.
        • Ricketts T.C.
        Defining urban and rural areas in U.S. epidemiologic studies.
        J Urban Health. 2006; 83: 162-175
        • Hart L.G.
        • Larson E.H.
        • Lishner D.M.
        Rural definitions for health policy and research.
        Am J Public Health. 2005; 95: 1149-1155