Community-Based Strategies to Reduce Alzheimer’s Disease and Related Dementia Incidence Among Rural, Racially/Ethnically Diverse Older Adults

Abstract

Purpose of Review

The purpose of this paper was to address the research question “What recent advances in Alzheimer’s Disease and Related Dementias (ADRD) risk reduction strategies can be tailored for rural, racially/ethnically diverse populations?” A rural resident’s life story that grounded the work is shared. Next, a brief description is provided regarding ADRD risk factors of importance in rural, multicultural settings. Gaps in U.S.-based research are highlighted. Policy actions and interventions that may make a difference in alleviating rural, ADRD-related disparities are offered.

Recent Findings

More than a dozen factors, including lack of built environment, periodontitis, poor air quality, and sensory loss, were identified that are of particular relevance to rural groups. Evidence of importance to underserved residents has also emerged regarding the harmful effects of ultra-processed foods on brain health, benefits of even minimal physical activity, and importance of social engagement, on brain health.

Summary

Resident-led initiatives will be key to creating change at the community level. Health providers are also called to assist in identifying and adapting culturally specific upstream approaches, in partnership with community stakeholders. These mechanisms are vital for decreasing ADRD burdens in underserved communities facing the largest disparities in preventive care.

A Story of Living Next to Sugar Cane Fields

Roseline grew up living in a rural ‘project’ in a southeast central Florida diverse farming community known as “the Glades”. The neighborhood was created by the sugarcane industry in the 1960s and has maintained a multicultural identity with 60.2% African American, 27.9% Hispanic, and 5.3% Afro-Caribbeans who are included in the 2 or more races [1]. As Rosaline’s father worked for “Big Sugar”, the family had the security of living in modest company housing where many expenses were covered. Her childhood was happy, and the community was tight-knit. Neighbors who were not working looked after Rosaline. She attended a nearby church, and her parents never worried about their home or car being vandalized. The neighborhood children were active and ran in the cane fields, chased rabbits or used the playground equipment provided by the company.

Cultural values focused on escaping a life of field work to avoid consistent exposure to “black snow”, a fine ash that fell during the sugarcane burning 8 months a year. As a child of immigrants, Rosaline understood her choices were either college, professional sports, or the military. Her father took advantage of the college plan offered by the sugar industry to secure his daughter’s future, as he moved up to a managerial position overseeing water storage in the fields. After high school graduation, she attended college at a well-respected state university and was exposed to movie theaters, coffee houses, grocery options, shopping districts, and exercise studios.

During her time away from her rural community, Rosaline grew to understand that she belonged to an “under-served” community, and there were numerous health risks in the Glades. Although she wanted to continue to live near the university, she chose to return to her home in the Glades and care for her parents whose health was failing. As immigrants from Haiti, her parents' early lives included economic hardship, poor health care access, and few educational or employment opportunities. In the Glades, similar conditions and limited opportunity beyond the sugarcane industry created negative social determinants of health. By mid-life, Rosaline’s parents struggled with memory decline and numerous chronic conditions, including hearing loss and poor vision. Roseline became aware that resources were extremely limited, even for herself. She had to travel 30-40 miles to access care providers who would schedule an appointment, instead of waiting all day in the office of care providers in the Glades. She struggled to find healthy food choices, especially foods that her parents could enjoy despite their dental problems. Smoking cessation support, current treatments for diabetes, and updated resources to manage hypertension were even harder to find. There were scant opportunities for socialization, formal exercise, or social clubs within 30 miles. Social opportunities for older adults with hearing loss were unavailable. Roseline felt that the lack of social outlets exacerbated misuse of alcohol in the community. Roseline reports that now as an older adult herself, these disparities have not changed. Currently, nearly half of Glades residents live below the poverty level. Although there are senior centers, older residents have to be mobile to participate. Exposure to the black ash from sugarcane burning, and lack of affordable healthy foods, social contact, continuing education opportunities, vision, hearing, and other specialty providers still exist.

Introduction

This story illustrates that older adults in rural communities are often known for their focus on family, self-reliance, and religiosity. They may distrust outsiders and embrace the belief that life events are predetermined [2]. People such as Roseline and her family are particularly at risk for ADRD because the high prevalence of chronic illness increases ADRD incidence [3, 4]. The East South-Central region of the U.S., which includes Florida, has the highest levels of ADRD-nonmetropolitan mortality, which may be due to historical disadvantage [5].

Rural residents thrive on remaining independent, even when independence amplifies chronic disease burden from health care disparities [2]. These disparities include low access to continued learning, socialization, and health care, as well as early detection and mitigation that could help them age in place[6•]. Recognition of these disparities and cost burdens associated with the growing number of rural residents ages 65 and over (17.5%) compared to urban older adults (13.8%) [7] is imperative. Changing demographics have spurred new attention to improve disease management including ADRD in rural communities. For example, the need for web-based communications, which was emphasized during the recent COVID-19 pandemic, resulted in new initiatives to provide computer access, hardware, and internet connectivity [8]. However, computer literacy training in rural settings has remained insufficient [9]. ADRD risk has increased in rural areas over the past 10 years [5], often due to the disparities described by Roseline. In the Glades region, only 60% graduate from high school, health literacy averages a 7-8th grade level, ethnic group membership is 91%, healthcare access is limited, and the poverty rate is an astounding 41% [10].

ADRD risk factors which disproportionately affect African Americans and Hispanic Americans (e.g., diabetes and hypertension) are compounded by disadvantage found in rural communities such as social isolation, limited social amenities, and insufficient access to care. In addition, rural communities are disproportionately affected by polluting practices in industry and agriculture [11, 12].

As highlighted by Roseline’s story, persons in rural settings need access to feasible, evidence-based, individual self-care activities that can be pursued without travel or technology to decrease the risk for chronic disease. ADRD prevention calls for health promotion strategies that support cognitive health along the continuum of aging. Brain pathology develops decades prior to symptoms in the preclinical stage of ADRD, but noticeable changes in daily life do not emerge until much later [13]. Therefore, this discussion of slowing disease progression of cognitive decline first focuses on understanding current health patterns that increase ADRD risk among rural, racially/ethnically diverse residents [14], and current research that specifically targets U.S. rural groups. We conclude with strategies categorized by primary, secondary, and tertiary levels of prevention, and suggest actions at the state and national levels to promote health engagement in under-served rural communities.

Definition of Rurality

Rural is defined by different organizations and agencies, depending on the purpose. There are 33 different ways in which the U.S. federal government defines rural [15]. A community-centric approach to defining rural was proposed by a group of rural scholars, who recommended creating an index comprised of major subcomponents of rurality, including population density, geographic isolation, resources, amenities, socioeconomic conditions, and local perceptions/culture [15]. Multiple measures could be incorporated into a given rurality subcomponent (e.g., resource category could be comprised of the number of hospitals, home health agencies, and providers per 1,000 population). The index subcomponents could be differentially weighted in calculating the overall index score, to acknowledge a place’s unique rurality characteristics. This identification of the rurality-based characteristics that are most important for a given locale would inform policymakers for targeted, place-based interventions. In this paper, rural is defined as “any area that is not urban” [16], and the characteristics are presented as potential factors in the prevention of ADRD [14].

ADRD Risk Factors in Rural, Racially/Ethnically Diverse Settings

In 2020, Livingston and colleagues [14] expanded the original list of potentially modifiable ADRD risk factors. We briefly describe these factors, combined with influences exacerbating cognitive risk that are important to rural, racially/ethnically diverse populations, followed by recent research specific to rural, racially/ethnically diverse settings. Table 2 includes preventative strategies that may be feasible in rural, diverse settings, categorized by levels of prevention. Three levels of prevention organize our approach to lowering ADRD risk. Primary prevention focuses on education regarding healthy lifestyle such as smoking cessation, healthy movement, avoiding STIs, adequate sleep, and no alcohol to moderate drinking. Secondary prevention emphasizes routine screenings for disease and prompt treatment. Examples of screening programs might include mammography, blood pressure checks, blood glucose, HbA1C, and cholesterol screenings. Tertiary interventions aim to increase quality of life and well-being in the presence of disease [17].

Table 2.

Three Levels of Preventive Strategies to Reduce ADRD Risk in Rural Communities

Risk Factor	Primary Prevention* (Education and advocacy)	Secondary Prevention (Screening and prompt treatment)	Tertiary Prevention (Promoting well-being in the presence of health challenges)
Smoking	Increase awareness of health dangers of smoking/vaping Advocate for policy changes to reduce nicotine access	Screen with disposable pulmonary function tests	Promote cessation patches, lozenges, and chewing gum to reduce/eliminate nicotine use
Air Pollution	Advocate for clean technology during sugarcane harvesting; Improve building codes to reduce in-home pollution, eventually reducing long-term societal costs.	Test homes and communities for air quality Screen for sleep apnea risks During sugarcane burning: Wear PM2.5- grade masks Use PM2.5-grade air filters Stay indoors, Modify outdoor physical activity	Provide access to follow-up medical care after screening to manage respiratory illnesses Arrange for transportation to specialists Person to accompany older residents during provider visits to enhance understanding, Obtain medications and sleep apnea equipment when needed
Built Environment	Inform residents of currently existing opportunities for health promotion, e.g., use of libraries and parks	Screen for unsafe housing, absence of parks, libraries, social gathering places (clubs, coffee shops, etc.) Form local interdisciplinary task forces to lobby for funding	Implement monthly community clean-up days Lobby for funding to replace dilapidated housing
Low literacy, low education (less than 8th grade)	Advocate for family strengthening programs Promote local educational opportunities Promote use of plain language and pictograms to promote disease awareness	Literacy screening Facilitate enrollment in adult literacy programs	Implement literacy programs in churches and libraries In-home literacy training small groups Do not require documented status for literacy programs, but do offer citizenship classes
Alcohol Intake	Advocate for no or limited alcohol intake according to CDC recommendations Substitute alternative beverages to decrease alcohol intake	Train health educators to screen for excessive alcohol intake and alcohol abuse in the home Refer to health and support services	Provide connections to local 12-step and other addiction support services Take daily thiamine intake if approved by provider
Depression and Other Mental Health Challenges	Build self-esteem in early life Encourage self-care activities Limit screen time Seek friends through: faith-based settings, hobby clubs, support groups, events at or near your residence -Participate in volunteer opportunities Start each day with a gratitude list Have someone contact at risk residents each day (Call 211 to arrange a “Sunshine Call” for older adults)	Screen for depression and other mental health challenges with age- and literacy-appropriate measures in community and healthcare settings	Organize outdoor activities Exercise with others Identify a support person Provide transportation and access to mental healthcare professionals
Insufficient Sleep	Increase awareness of health risks of excessive caffeine Limit vigorous activity or heavy eating before bedtime Review medications with nurse, pharmacist, or provider Promote: daytime exercise meditation prayer listening to calming sounds at bedtime bedtime routine avoid boredom and stress (work, volunteer, learn a new hobby)	Screen for sleep patterns and neighborhood noise level Refer for sleep study to screen for Obstructive Sleep Apnea	Recommend/provide ear plugs and white noise devices Manage symptoms of chronic conditions that interfere with sleep
Traumatic Brain Injury	Promote helmet-wearing for sports, fall prevention strategies, safe driving, road improvement designs to prevent accidents Increase lighting Provide ramps for common step-down areas in public spaces such as grocery stores and post offices	Follow TBI protocols for assessment Expand access to screening for falls e.g., health events/fairs, Local safe-driver assessments Screen annually for vision loss	Train rural providers/ER staff to follow TBI head injury protocols Review medications with nurse, pharmacist, and/or provider Establish means for feasible transportation to trauma facilities
Hypertension	Education regarding the MIND diet and culturally appropriate options Teach mindfulness and stress management techniques Encourage community members to find exercise routines that are enjoyable and consistent	Screen with follow-up Provide BP monitors or wearable technology in home Know triggers that raise stress levels, and self-monitor BP	Provide support for adhering to medications through prescription support (obtaining, filling, and compliance with) Arrange home care to prepare pill boxes Educate family members regarding signs of stroke
Diabetes Mellitus	Train and educate regarding the importance of a balanced diet and consistent exercise Access to foods that meet health goals, are palatable, and culturally appropriate Education regarding the role of insulin and glucose, and the importance of maintaining a healthy blood sugar level	Screen with follow-up Identify community members with a HbA1c between 5.7% and 6.4% as prediabetic and encourage lifestyle modifications to correct blood glucose levels	Educate family members in signs and symptoms of hypo/hyperglycemic episodes Facilitate access to insulin and other necessary medications for DM Provide glucose monitors or wearable technology in home
Hearing Loss	Increase awareness of health risks associated with loud noise/music levels Promote wearing earplugs or noise-canceling devices	Advocate for annual free screening and affordable hearing aids	Enable access to affordable, effective, accessible (not just magnifying) hearing aids
Vision Impairment	Recommend/provide sunglasses in bright sunshine to slow development of cataracts Partner with Lion’s Club to provide free eyewear	Offer annual free vision fairs with providers present, Screen for glaucoma and macular degeneration	Wear corrective lenses Surgical treatment of cataracts Treatment to prevent further macular degeneration, medications to prevent glaucoma
Periodontitis	Teach importance of oral hygiene throughout the lifespan with most recent evidence-based methods of brushing and flossing Provide toothbrushes and toothpaste Provide access to professional dental cleanings	Annual free screening for oral health during community events with providers present Consider staffing dental professionals in Emergency Departments for prompt treatment	Annual dental fair to treat cavities Treatment for periodontal disease to prevent bacterial overgrowth
High Calorie Intake, High intake of processed foods	Advocate for accessible cooking classes Education regarding the MIND Diet and Strategies to increase access to, and acceptance by rural populations of nutrient dense foods e.g. canned tuna with avocado on tacos Work with organizations to provide MIND foods adapted for local rural setting Raise awareness of health risks of processed food intake (Hecht et al. [69, 98] Promote community engagement such as a cooking fairs or potlucks with MIND meals	Screen older adults for increasing or decreasing BMI Daily Vitamin for persons over 50 (one-a-day + 50 shown to decrease dementia risk) [97] Advocate for insurance coverage	Advocate for accessible weight-loss support and treatments
Low Activity Level	Minimize screen time Plan time in green spaces Optimize activity opportunities at home (e.g. exercise with soup cans, pair social activities with exercise) Walk when: Talking on the phone During a meeting with 2–3 persons Watching television (walk or exercise in place) Park car the furthest away from the door	Self-assessment of exercise through wearable technology	Access to home and community exercise classes with disability adjustments as needed
Low Social Contact	Increase awareness that social isolation and loneliness are significant personal and public health threats Increase awareness that social contact is a protective factor to decrease risk of dementia Promote limited screen time	Screen for loneliness Screen for amount of social interaction and support provided by friends, family, pets, neighbors, and/or community	Pair high school visitors to older adults Promote youth and adult community social activities, e.g., through religious organizations, public libraries, daycare centers, and/or sororities/fraternities Implement community-based peer led programs Organize “reach out” activities, e.g.; sunshine calls, use of therapy animals at community events Promote built environment to support social interactions, e.g., benches outside senior living areas Promote volunteerism

The next section describes the way in which each risk factor is related to Roseline’s story, the impact of the risk factor on ADRD, and if found, the prevalence and research relevant to rural, racially/ethnically diverse residents. We searched in PubMed for peer-reviewed articles within the past five years (February 2019-February 2023), using the terms “rural” “racially, ethnically diverse”, “dementia”, and the related risk factor term (e.g., “vision loss” which elicited no papers). Due to their importance in Roseline’s story, three risk factors are addressed further in the narrative, limited availability of healthy foods, low physical activity, and low social contact.

Smoking

Although Roseline’s family members did not smoke, cigarette smoking is more prevalent in rural areas than urban [18]. Increased frequency and duration of smoking over 50 years is known to reduce hippocampal volume, thereby increasing risk for cognitive decline [19]. Evidence suggests that smoking cessation may reduce risks to brain health through recovery of microstructural pathways [20]. Researchers point out that rural and racially/ethnically diverse residents have been “left behind” in the recent successes to decrease smoking rates [21] and have called for more efforts to reduce this disparity and diminish smoking-associated chronic illnesses, including ADRD [22]. Otherwise, research targeting rural residents who are also racially/ethnically diverse is scant.

Exposure to Poor Air Quality

Chronic air pollution from sugarcane burning as described by Roseline is characterized by air particles or droplets 2.5 microns or less in width (PM2.5). These air particles or droplets increase oxidative stress, which bolsters systemic inflammation. PM2.5 exacerbates cardiorespiratory health hazards (81%) and ADRD risk (92%) [23], especially among racially/ethnically diverse rural residents [24]. The adverse effects of PM2.5 are most detrimental among those with 8 or fewer years of education, which is more common in rural areas, especially among racially/ethnically diverse populations [25]. Studies on the impact of PM2.5 on U.S. rural older adults at risk of ADRD are scarce, although recent published findings conclude that rural air pollution may be just as harmful as urban settings [26].

Roseline’s story is congruent with a recent scoping review of patterns of alcohol use across diverse rural settings. Heavy alcohol intake is defined by the Centers for Disease Control (CDC) as more than 14 drinks per week for men, or more than 7 drinks per week for women [27]. Long-term overuse of alcohol is known to reduce the hippocampus, thereby negatively impacting memory and learning. Excess alcohol consumption can also increase stroke and diabetes risk, leading to greater ADRD risk [28]. Researchers have concluded that regardless of geographic location or race/ethnicity, region and culture still remain the primary influence on alcohol intake [29]. For example, the South has the lowest alcohol consumption rates in either rural or urban settings, while the Midwest has higher rates. Research that is community-centered is needed to identify the specific patterns of alcohol use and design effective interventions to decrease excess intake.

Depression and Other Mental Health Challenges

In rural and racially/ethnically diverse communities, families such as Rosaline’s likely maintain a strong sense of independence, adhere to cultural influences such as religiosity, and experience familial and personal stigma [30]. Mental health promotion and prevention education are often scarce in rural communities, all of which are barriers to understanding, identifying and seeking treatment for depression or other mental health challenges. Poverty, limited or no access to transportation, few social opportunities, and lack of health care coverage add to these existing disadvantages that impact the acceptability, affordability, availability, and accessibility to quality mental health care in rural areas [31]. These rural-based disparities are particularly concerning for racially/ethnically diverse older adults. Early onset late-life depression beginning before age 60 in those predisposed to ADRD increases the risk for its development, whereas late-onset depression occurring after age 60 is likely an aspect of the prodromal stage of cognitive decline [32]. The resolution of depression at any time decreases the risk for ADRD emphasizing the need for effective preventive strategies. When conducting research related to mental health and risk for ADRD, specific statistical analyses with stratification by geographic location, race, and ethnicity are needed to identify specific health disparities of older adults residing in rural areas [31, 33]. Additional studies to examine the effects of the neighborhood and built environment on mental and cognitive health of racially/ethnically diverse older adults in rural areas are imperative [34]. Studies designed to evaluate the impact of pollution, unsafe water, loud noises, crime, security, and walkability among others [35] will advance knowledge and understanding of health disparities to promote and create meaningful and effective interventions and promote public policies that improve mental health and well-being of rural, racially/ethnically diverse older adults.

Inadequate Sleep

In Roseline’s community, sacrificing sleep hours to meet the heavy responsibilities at home after working long hours in the fields contributes to sleep deprivation. Early morning noises of crop-dusting planes, farm machinery, and tractor-trailer trucks transporting agricultural goods in rural communities can exacerbate and contribute to inadequate sleep [36]. Poor sleep quality, defined as less than 7–8 h of uninterrupted sleep, increases ADRD risk by what is believed to be the interruption of normal clearing of Amyloid-β pathology [36] forming in the brain. Amyloid plaques are associated with decreases in executive function, attention, and visuospatial ability [37]. Although studies demonstrated that poor sleep among racially/ethnically diverse residents, especially those with hypertension, led to increased ADRD risk, the results were not replicated from a recent study conducted in Roseline’s region [38].

Traumatic Brain Injury (TBI)

In rural and urban communities, TBI is typically associated with motor vehicle accidents, suicides, and unintentional falls [39]. However, in Rosaline’s community, the local high schools are nationally known for their superior football programs increasing the athletes’ risk for TBI. TBI increases dementia risk due to axonal injury and interruptions in neuronal transport that contribute to increases in amyloid-β peptide and hyperphosphorylated tau proteins associated with Alzheimer’s disease [40]. Unfortunately, lack of TBI protocol awareness, combined with absence of certified personnel trained in concussion protocols, and low use of standardized cognitive assessment/testing, is prevalent in rural communities [41]. TBI-fatality rates are 23% higher among rural residents than urban. This disparity is alarming, as persons experiencing a TBI-related loss of consciousness are at 50% increased ADRD risk compared with those without [39]. TBI-focused clinical trials in rural, racially/ethnically diverse settings are needed to show effectiveness of education and training in decreasing ADRD risk.

Hypertension

In rural communities such as Roseline’s, hypertension-related mortality is significantly higher than is observed in predominantly White and urban areas [42]. The current age-standardized prevalence rate of hypertension in the most rural communities is 34.1% whereas most urban areas have a 28.5% prevalence rate [43]. Limited access to and availability of specialty healthcare providers, lack of transportation, and limited access to healthy foods contribute to the higher rate of cardiovascular conditions [43]. Hypertension is commonly comorbid with other conditions such as cardiovascular disease, cancer, diabetes, and kidney disease [42]. Autopsy studies have shown that hypertension is related to ADRD neuropathological changes [44]. Furthermore, hypertension in midlife is associated with developing ADRD in late life [45]. Chronic hypertension affects the structural and functional integrity of the cerebral vasculature, decreasing blood supply, disrupting integrity of the blood brain barrier, promoting neuroinflammation, and possibly contributing to amyloid deposition and ADRD pathology [46].

Diabetes Mellitus (DM)

Residents of rural areas in the U.S. are at an increased risk for DM due to limited access to important DM education and care, such as dilated eye exams [47]. Identified barriers to self-care also include the cost of medication, lack of culturally competent recommendations and guidelines, and poor transportation infrastructure. Women and men with DM are 120% and 70% more likely, respectively, to be diagnosed with AD compared to those without DM [48]. DM-related changes in glucose/lipid metabolism result in oxidative stress, mitochondrial dysfunction, and brain changes associated with Amyloid-β pathology [47]. DM prevention and management as an intervention has shown strong evidence of preventing ADRD [49], however, research that tests additional interventions to diminish DM threats among rural populations are needed.

Sensory Loss

For more than a decade, researchers have pointed to the association between sensory loss, such as declining hearing and vision, with cognitive decline due to structural/functional brain changes, increased cognitive load, interference with supportive relationships, and diminished socioemotional well-being thereby increasing ADRD risk [50, 51].

Hearing Loss

Hearing loss affects approximately 7 out of 10 adults over age 70 in the U.S. [52], and untreated hearing loss is more prevalent in rural areas related to barriers to accessing hearing care [53]. Researchers have found that difficulty hearing spoken conversations was associated with up to 91% increased ADRD risk in 82,000 participants [54]. Significant hearing loss even reduces telephone use, which further isolates affected aging adults. More than one sensory impairment leads to dependency, sedentariness, and ultimately becoming homebound [54]. Rural farmworker residents are exposed to loud machinery for many years without access to noise reduction earmuffs. Rural residents reported an average travel time to audiology services of more than one hour compared to 32 min for urban residents. Rural residents also reported that hearing loss prevented them from participating in educational opportunities [55]. The cost of hearing aids or cochlear implants remains prohibitive for many, not just rural residents. Lower-cost hearing devices that simply amplify the sound are being sold over the counter, but effective solutions for hearing loss in underserved communities, other than primary prevention (education to wear earmuffs, lower music volume, etc.) are not available. We did not find relevant research that targets both rural, and racially/ethnically diverse residents.

Vision Loss

In a recent systematic review of 110 articles, researchers confirmed that vision impairment was associated with cognitive loss [55], however, studies involving vision changes among rural, racially/ethnically diverse older U.S. residents was identified as a gap in the literature. Serious visual impairment constrains mobility and participation in social events thereby contributing to the cycle of sensory loss and limited social participation [56]. This is important as rural residents often lack access to ophthalmologists or optometrists.

Periodontitis

Rural communities like Roseline’s often do not have adequate access to dental health education and dental care [57]. Low income, rural residency, and being a member of a racial/ethnic group are associated with increased rates of poor oral health [58]. One retrospective cohort study found the presence of pathogens that cause gingivitis significantly increased the risk of ADRD, particularly among adults over 65 years old [59]. The exact pathway from increased oral bacteria to ADRD is unknown, but oral bacteria may either contribute directly to Amyloid-β pathology or indirectly by increasing neuroinflammation [60].

Lack of a Supportive Built Environment

Built environment includes human-made physical spaces such as commercial destinations, parks, walking paths, and roads, whereas neighborhood social environment includes socioeconomic status, neighborhood disorder and social support [11]. Restrictive built and neighborhood social environments have been recognized for their importance in chronic conditions, such as diabetes, asthma, depression, and sleeping problems [61], which in turn are associated with increased ADRD risk. Rural residents more often experience lack of sidewalks and safety concerns in their communities as evidenced in Rose’s story by the abandoned buildings, broken window, and graffiti located downtown [62]. These aspects of neighborhood disorder diminish the ability to socially engage with others, which leads to social isolation [11].

As in many other ADRD risk factors reviewed in this article, living in a racially/ethnically diverse urban setting is associated with poorer health outcomes, but built and neighborhood social environments in rural communities have rarely been investigated. However, current research by Besser and colleagues demonstrates the negative impact of neighborhood decay in rural, and/or disadvantaged neighborhoods. They report that previously identified health-promoting built environments such as mixed land use have been associated with better brain health and lower risk of cognitive impairment [63-65]. Although research on rural social community activities and cognition level are available in other countries such as England, Japan, and China [66], there is a scarcity of U.S.-based research focused on rural, racially/ethnically diverse populations.

Food Choices that Threaten Brain Health

Attaining healthy foods, like those Roseline sought for her parents who needed to make health-related dietary changes, can be surprisingly difficult in rural areas. Older adults, especially rural residents, may not have access to, or even be aware that diets high in processed foods, fat and carbohydrates, and low in vegetables or fruits, can contribute to cognitive decline. Ultra-processed foods (UPFs) which contain industrial ingredients used as preservatives, stabilizers, and sweeteners [67] are also an important threat to brain health among middle aged and older rural residents. In longitudinal studies, researchers reported that consuming 19.9% or more calories from UPFs was associated with faster cognitive decline compared to diets with less UPFs [68]. In a large study of 10,359 American adults, Hecht et al. [69] found that those who consumed a higher proportion of UPFs in their diets had greater odds of being obese, sedentary, reported more frequent mental health symptoms, such as depression and anxiety, than those who consumed fewer UPFs. Adults with the highest intake of UPFs were more likely to be Black or Hispanic. Unfortunately, rural versus urban residence was not reported.

Obesity, DM, and low physical activity are more common among Blacks compared to Whites, but among rural residents, people of all races are more likely to be obese and less active compared to urban residents [70]. Being overweight or abdominally obese is also associated with increased ADRD risk, regardless of physical activity level and other factors [71], possibly due to increased inflammation in the brain, circulatory changes, and impact from diet-associated chronic risks such as DM and uncontrolled hypertension. Conversely, low BMI is also a risk factor for older adults, and older adults with falling BMI need to be screened for cognitive impairment [49].

Rural-dwelling Blacks face significantly higher odds of obesity, an ADRD risk factor, than respondents in urban areas per a Behavioral Risk Factor Surveillance System study (n = 359,157). Low educational attainment, low access to quality healthcare, and fewer healthy behaviors were found to contribute to the disparities [70]. Research is needed to uncover the causal relationships among obesity, food choices, ADRD, and related variables.

Low Physical Activity

Although the term “rural neighborhood” as illustrated in Roseline’s story may stimulate images of open spaces where farm/field work is strenuous, in fact, safe walking areas or places for health-related fitness activities are often limited. Three areas of the brain appear to be negatively impacted by physical inactivity; hippocampal volumes, vascular physiology, and neurogenesis [72]. A recent literature review concluded that persons with ADRD who reported long-term exercise interventions appeared to improve these three brain functions which provided some protection against cognitive decline [73]. Furthermore, Müller et al. [74] shared research that physical improvements in balance, endurance, and gait speed gained from being physically, active lowers mortality risk among persons with ADRD [75], while maintaining sense of self [76] and enhancing quality of life [77].

Researchers have illustrated benefits of structured exercise opportunities among rural residents. For example, 75 adults ages 50 or older who participated in a community-based program focused on decreasing dementia risk through education, behavior change, or exercise showed significant change in participation in physical activity over time, particularly in those with higher dementia prevention knowledge scores, but not in behavior change [62]. This suggests that the participants strongly supported and understood the importance of dementia prevention by attending routine group classes. Since driving to community sites was required, this may create a barrier for some older adults, particularly the underserved. In a recent pilot program, high school students taught seniors in their homes how to use tablets, provided with local grant support, and accessed online chair yoga classes. The program was successful in both increasing activity and improving cognitive scores over three months [78]. Another solution may be to empower rural residents through three home-visits to engage in resistance exercise with light weights, showing them how to do basic exercises during regular daily activities, such as television viewing or talking on the phone. This is important because compared to aerobic activities, consistent low doses of resistance exercises can produce clinically meaningful improvements in cognition [77, 79]. For persons diagnosed with dementia (N = 436), researchers found that the engagement in leisure activities such as gardening and riding a bicycle was more likely when living in a rural environment than urban (OR = 2.02) [74]. This is encouraging for rural residents.

Rural-dwelling Blacks are significantly less likely to engage in physical activity than respondents in urban areas, per the Behavioral Risk Factor Surveillance System (n = 359,157) [70]. Reasons for this disparity that increases ADRD risk are numerous. Rural, racially/ethnically diverse neighborhoods have been found to have less opportunities for leisure-time physical activity and exercise, and residents held perceptions that prevented them from attending activity centers. For example, Cohen and colleagues found that lower-income residents did not feel as welcome or connected to town centers, where opportunities for activities were more available than their own neighborhoods [80]. Regardless, it is essential to inform people to take any opportunity to avoid sitting still. A person who is in bed for one week starts losing cognitive ability. Being active also helps to decrease depression, aches and pains, hypertension, diabetes, obesity, and increase positive mood, sleep, and outlook on life. A brief 30-min walk immediately increases positive mood through boosted brain chemistry [81, 82].

Low Social Contact

An issue that matters greatly to Roseline is the lack of social clubs and activities, other than church- or school-based, throughout the Glades. Few opportunities for social contact in rural settings increase the possibility that racially/ethnically diverse older adults experience social isolation, which may be even more consequential for those living with hearing loss or without adequate transportation. Studies demonstrate that persons who have low social contact or are socially isolated have an increased risk for ADRD [14]. However, research lacks consistent definitions of social constructs, e.g., social contact, social networks, social isolation, and social support, leading to inconsistent findings [83, 84]. In a recent systematic review (n = 65) and meta-analysis (n = 51), older adults (n = 102,035) who participated in increased social activities and had large social networks, indicating decreased social isolation, were significantly associated with better cognitive function in later life (r = 0.054; 95% CI, 0.043, 0.065) [83]. The effect of large social networks on cognitive function remained statistically significant for both women and men. In addition to human social contact, studies indicate that pets may provide needed companionship and encourage beneficial social connections in older adults [85, 86]. Despite the current research on social contact and risk of ADRD, studies focus either only on rural [87•, 88] or on racially/ethnically diverse older adult residents [89]. Future studies should include both characteristics (rural, racially/ethnically diverse older adults) to clarify their effects on the relationship of social contact to cognitive function and determine the types of social activities that are acceptable, affordable, feasible and effective among this underserved population.

Policy Implications

The importance of pursuing preventive measures in rural settings to delay onset of ADRD as described above was recently illustrated in a new study of over 1600 southern U.S. community-dwelling Black and low-income residents [90]. Using Medicare ADRD claims data, a composite score was created, based on patterns of sleep, smoking, diet, leisuretime physical activity, and alcohol consumption. Hazard ratios (HRs, 95% CIs) for incident ADRD were calculated for ADRD incidence, using Cox regression. A dose-response association was associated with up to 36% reduced ADRD risk. This indicates the need to provide preventive health options in rural, racially/ethnically diverse settings. Prevention begins with education in every risk factor across the lifespan. Resident-led initiatives will be crucial in creating change at the community level.

Studies are needed to show the cost-benefit of prevention strategies. For example, replacing ineffective air filters with newer models that reduce indoor PM2.5 air pollution [91] would lower long-term care costs from air-related health hazards. Ultimately, new policies are needed to reduce indoor and outdoor air pollution [91].

Policies and programs such as those suggested in Table 1 are needed to support the transition from environmentally harmful methods to safe, sustainable technologies that support the health of agricultural communities such as the one described by Rosaline. Nurses can influence the process by creating and disseminating convincing evidence to community members, health care providers, educators, policy makers, and media to support policy-related actions at the local and state levels, to improve health and reduce healthcare costs [92].

Table 1.

Local and State Policy Actions to Promote Brain Health in Rural, Diverse Settings

LOCAL LEVEL ACTIONS
i. Create resident-led local health advisory boards that will include trained local health educators
ii. Meet weekly at a consistent time to plan rotating health screening events at neighborhood centers, churches, city halls, playgrounds, etc.
iii. Engage retired and local providers to donate services during health events
iv. Work with local churches, schools, libraries, first responders, fraternal organizations, etc. to identify “neighborhood ambassadors”, to
distribute monthly flyers of events with phone numbers and locations for food banks, opportunities for free exercise programs, socialization
events (community events), health education programs, and volunteer transportation services. Use donations from local print services or
community foundations to print flyers.
v. Partner with legal aid to enroll persons in sliding scale or no-cost insurance
vi. Create work-study, and outreach courses with the closest college and vocational tech programs. Service-learning, examples include conducting local health screenings and follow-up phone calls to facilitate next steps with residents attending health screenings
vii. Work through local high schools to pair student volunteers selected by guidance counselors to provide training to older adults in computer literacy
viiii. Provide bus passes or coordinate rural rideshares for older adults to participate in health promotion activities, e.g., provider visits, exercise classes, health fairs
ix. Partner with local governments to improve lighting, sidewalks, siren use, and school start-times
x. Create resident-led local health advisory boards that will include trained local health educators

Conclusion

In this paper, a brief appraisal of ADRD risk factors that are relevant and potentially modifiable in rural and racially/ethnically diverse settings were described. This review identified gaps in U.S.-based research regarding these ADRD risk factors. Preventive health strategies to address each factor were offered, and policy-based actions at the local and state were suggested.

We emphasize the importance of launching ADRD awareness campaigns in early childhood, since lifestyle patterns predict the life course of the disease. Brains in persons ages 60–91 without cognitive impairment have shown very minimal (0.5–1%) shrinkage, and the “oldest old” with normal cognition show none to very mild atrophy [93]. Healthy life-styles at any age can aid in slowing deleterious changes, and exciting advancements are emerging to support healthy aging. These new directions include providing pneumonia vaccinations between ages 65–75, which has been shown to reduce risk of AD following illness. This confirms findings of the links between viruses and neurodegeneration [94]. Additional tests are underway for an anti- Amyloid-β vaccine, which has previously shown effectiveness among those living with Down syndrome [95]. Cognitive training improves the related domain and transfers to daily cognitive function [96], which would help rural, racially/ethnically diverse older adults to age in place if they are provided training opportunities.

For every ADRD risk factor, primary prevention would include offering local language and culturally relevant health promotion education programs in churches and libraries. Targeting primary care provider offices with video programs, picture pamphlets, and engaging nursing students to teach patients in waiting rooms as part of their community health clinical hours is needed. For a list of rural-specific preventive actions, refer to Table 2. We urge health providers to identify and adapt culturally specific upstream approaches, in partnership with community stakeholders, as the mechanism for decreasing ADRD burdens, particularly in underserved communities facing the largest disparities in preventive care and treatment.