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