Table 1.
Overview of included studies.
| Author (Year) | Country | Population and Sample Size | Methods | Types of geographic inequalities | Findings |
|---|---|---|---|---|---|
| Abner et al.[1] | Kentucky, USA West Virginia, USA |
1209,976 Medicare beneficiaries in Kentucky and West Virginia | Quantitative: Completely ecologic analysis |
Rural/Urban Differences, State-Level Variations in diagnostic prevalence rates |
After adjusting for various factors, ADRD prevalence in rural counties in 2013 was 11 % lower than in urban counties (95 % CI: 9 %−13 %). This lower prevalence may indicate underdiagnosis in rural areas, possibly due to the study’s ecologic design and demographic differences, such as a younger and more male population in some rural areas. |
| Alty et al.[2] | Tasmania, Australia | 130 adults who live in Tasmania with at least 3 months of cognitive symptoms | Quantitative: Cross-sectional evaluation |
Rural/Remote access to cognitive assessments and dementia diagnosis | The new single-visit cognitive clinic in Tasmania efficiently provided same-day diagnoses to 98.5 % of patients, with 36.8 % from rural/remote areas. The model reduced the wait time from referral to diagnosis by 2 months compared to national benchmarks. |
| Battista et al.[5] | Italy | 336 Speech and language therapists | Quantitative: Survey |
Barriers to Service Access | Out of 336 speech and language therapists (SLTs) surveyed, 140 had experience with primary progressive aphasia (PPA). These SLTs reported seeing an average of 3 PPA patients each over the past 24 months. SLTs with experience disclosed geographical barriers and service dysfunction as major factors limiting patient access to therapy. |
| Bayly et al.[6] | Canada | 19 health care providers | Qualitative: Semi-structured Interviews |
Inequalities in dementia care quality and educational resources in rural settings | The implementation of integrated knowledge translation (iKT) strategies with the help of a knowledge broker (KB) in two rural home care centres improved dementia care by enhancing providers' knowledge and capacity to use best practices. |
| Bouldin et al.[8] | USA | 7436 caregivers | Quantitative: Cross-sectional observational study |
Financial and health barrier between rural and urban caregivers across 10 states. | Caregiving was more common in rural areas (21.4 %, 95 % CI: 20.4 −22.5) compared to urban areas (19.0 %, 95 % CI: 18.0 −19.9; P = 0.0005). Rural caregivers faced more financial barriers (38.1 % vs. 31.0 %) but had similar health barriers compared to urban caregivers. |
| Brady et al.[9] | Ireland | 8 general practitioners, 1 person living with dementia, 7 family members of people living with dementia |
Qualitative: Semi-structured interviews |
Diagnosis inequalities throughout regions | Dementia is significantly underdiagnosed in Longford-Westmeath, Ireland. Rural areas face significant gaps in dementia awareness, limited diagnostic resources, and fewer specialist services compared to urban areas. |
| Constantinescu et al.[13] | Alberta, Canada | 16 family physicians | Qualitative: Semi-structured focus groups |
Rural-Urban differences in family physicians’ challenges in providing dementia care | Rural family physicians struggle with limited knowledge about dementia symptoms, diagnostic processes, and advanced diagnostic tools. Challenges include limited access to specialist services, long wait times, and inadequate community resources for dementia care. |
| Cooper et al.[14] | United Kingdom | 77045 patients with recorded dementia diagnosis or anti-dementia drug prescription | Quantitative: Observational cohort study |
Regional variations in access to anti-dementia drugs | Northern Ireland: 81 % more likely to prescribe anti-dementia drugs than England (incidence rate ratio 1.81, 95 % CI: 1.41–2.34). Wales: 32 % less likely to prescribe compared to England (incidence rate ratio 0.68, 95 % CI: 0.55–0.82). Scotland: Prescribing rates showed a trend towards being higher than in England (incidence rate ratio 1.14, 95 % CI: 0.98–1.32). |
| Cotton et al.[15] | USA | 10 informal caregivers residing in socially disadvantaged areas | Qualitative: Semi-structured interviews |
Caregivers’ experiences with supportive services in under-resourced areas |
Caregivers in socially disadvantaged areas often turn to supportive services in response to crises or unmet needs, following a sequence of seeking, initiating, and using services. |
| Czapka et al. (2020) | Oslo, Norway | 7 migrants in Oslo engaged in transnational caring activities for their parents living with dementia. | Qualitative: Semi-structured interviews |
Differences in Care Systems across caregivers’ country of residence | Migrants face significant difficulties in transnational caregiving for parents with dementia, including redefining care roles, developing new strategies, and negotiating care scope with family members in the country of origin. |
| Dal Bello-Haas et al.[17] | Canada | 154 Rural, community-dwelling individuals with mild to moderate dementia and their caregivers. | Mixed methods: Survey and semi-structured interviews |
Inequality of accessing exercise interventions for individuals living in rural areas. | 50 % of surveyed patients and caregivers showed interest in telehealth-based exercise interventions. Willingness to participate in group exercise significantly predicted interest in telehealth, accounting for 24.4 % of the variance (F-statistic=16.14, p < 0.001). |
| Forbes et al.[18] | Canada | Nine rural dementia care networks consisting of PWD (n = 5), care partners (n = 14), and HCPs (n = 14) | Qualitative: Interviews |
Inequalities in dementia care between rural and more urban areas. | Rural areas face significant barriers in dementia care due to limited community resources and integration, with caregivers relying heavily on local and personal sources for information. Persons with dementia often do not recognise their need for care information, leading to potential isolation for caregivers. |
| Gibson et al.[19] | Midwest USA | 11 rural caregivers of persons with dementia | Qualitative: Semi-structured interviews |
Access to dementia-specific services between rural and urban areas. | Rural caregivers of persons with dementia face unique challenges, including financial concerns, geographic barriers, and a lack of dementia-specific services. Despite these challenges, many caregivers found strength and support within their community, which often served as a safety net. |
| Haydon et al.[25] | Australia | 73 people from three Aboriginal Medical Services and communities. | Qualitative: Focus groups and interviews |
Providing dementia care for people living in rural and remote area | Rural caregivers of persons with dementia have different needs than urban caregivers, requiring tailored outreach and services. Effective interventions should target multiple systems to promote social change for marginalised populations. |
| Hicks et al.[26] | England | 17 rural-dwelling older men with dementia | Qualitative: Open interview |
Access to dementia care and support services | The study identified two main themes. First, rural living offered benefits like a pleasant environment and supportive networks. Second, challenges included lack of dementia awareness and physical and motivational barriers. These findings highlight how the rural environment both helps and holds back older men with dementia, leading to recommendations for promoting social inclusion. |
| Jørgensen et al.[29] | Denmark | Danish individuals aged 65 + from January 1, 2000, and followed those without Alzheimer’s from January 1, 2008, until diagnosis, death, emigration, or December 31, 2009. | Quantitative: Regression analysis | Distance to an Alzheimer clinic and association to Alzheimer diagnosis | Individuals diagnosed with Alzheimer’s between 2008 and 2009 had a shorter average distance to clinics (16.6 km) compared to those not diagnosed (19.1 km) (P < 0.001). Distance to clinics inversely affected diagnosis likelihood, with hazard ratios of 0.80 (95 % CI: 0.70–0.92) for 20–39 km and 0.65 (95 % CI: 0.52–0.81) for 40–59 km, indicating that greater distances were associated with fewer diagnoses. |
| Krutter et al.[30] | Austria | 107 family caregivers | Mixed methods: Questionnaires and regression analysis |
Home care nursing in a rural setting | Higher age of family caregivers and female gender of persons with dementia (PwD) are key factors influencing the use of home care nursing in rural areas. |
| Li et al.[31] | Illinois, USA | 109 rural older adults with Alzheimer’s disease |
Mixed methods: Telephone interviews and regression analysis |
Unmet home care service needs | 53.2 % of patients experienced unmet service needs. Unmet needs were most frequently reported for bathing (30.9 %), dressing (27.1 %), walking (26.3 %), housekeeping (32.6 %), meal preparation (22.6 %), and transportation (22.1 %). Caregivers who experienced a higher level of burden were likely to report a higher rating on unmet service needs (β = −.18, p = .06). |
| Loup et al.[32] | Alabama and Mississippi, USA | 30 rural-dwelling dyads, individuals with dementia (n = 12) and informal caregivers (n = 18) | Qualitative: Semi-structured interviews |
Resource needs | Dyad #2: difficulties driving due to troubles getting PWD in the car and needing to travel to a distant physical therapist two times each week. Dyad #5: need to increase PWD’s mobility beyond his house to get him to care appointments. Dyad #4: takes a day to complete grocery shopping due to driving distance and physical demands. |
| McPherson [33] | Rural Washington, USA | 17- informal caregivers (n = 12), community members (n = 5) | Quantitative: Survey |
Patient-caregiver dyad support groups | 47 % responded neutral that there were support services for people with early stage AD. 47 % agreed that there were support services for informal caregivers of people with early stage AD. 4 participants stated that they do not know of any early stage AD support services. 70.6 % were neutral on the location of services. Information about services was the most recognised barrier to accessing support (29.4 %). Responded neutral that location of services, transportation to services were barriers to accessing support services. |
| Morgan et al.[34] | Saskatchewan, Canada | 11 directors of care and 4 family caregivers | Mixed methods: Focus groups and survey |
Barriers to use of formal services | Stigma of dementia due to it being associated with mental illness and the generation that it is hitting. Lack of privacy and anonymity due to living in a rural area where one’s activities were likely to be observed and discussed. Lack of information about the availability of services. Access to experts in assessment and management was limited in rural areas. Distance to services was a barrier. Limits on the amount and types of service that could be obtained in a given time period were also issues. The cost of home services was a deterrent. |
| Ouvrard 2020 [35] | France | 3431participants aged 65 years or over | Quantitative: Epidemiological cohort study. |
Impact of geographical deprivation on risk of dementia | There was no association between geographical deprivation and risk of dementia, except for the participants in the Q3 (second most geographically deprived) compared to those in the Q1 (least geographically deprived) (HR=1.35; 95 % CI: 1.06, 1.72). |
| Teel [42] | A mid-western state, USA | 19 primary care providers | Qualitative: Semi-structured interviews |
Diagnosis and treatment | Several PCPs pointed out difficulties in trying to access or coordinate consultation, either due to infrequent visits by consultant to the PCP’s rural area, the extreme distances patients had to travel to the specialist’s office, or the delays in getting appointments. Difficulties in communicating with the family and limited community resources. |
| Thorpe et al.[43] | USA | 1186 community-dwelling older male veterans with dementia and their female informal caregivers. | Quantitative: Observational cross-sectional |
Preventable hospitalisations among community-dwelling veterans with dementia | Compared to those in large metropolitan counties, the odds of having an ACSH (ambulatory care sensitive hospitalisations) were 1.99 times greater for care recipients living in noncore counties (12.8 % vs 22.6 %; OR=1.99, p < .01) Odds of ACSH did not differ significantly between large metropolitan counties, small metros, and micropolitan counties. The relationship between county rurality and non-ACSH was not statistically significant. |
| Vipperman et al.[45] | Appalachia | 124 family caregivers of people living with dementia. | Qualitative: Telephone interviews |
Barriers to service use among dementia family caregivers | Caregivers’ capability of seeking services had a marginal effect on support service use (IRR=0.71, p = 0.07). Caregivers who experienced financial barriers (OR=0.001, p < .01) and those who were reluctant to use services (OR=0.02, p < .01) had significantly lower odds of using personal care services. |
| Watson et al.[47] | England | 142,302 people living with dementia. | Quantitative: Observational study |
Inequalities in primary and secondary healthcare | People living with dementia from rural areas have greater use of healthcare services more closely associated with negative health outcomes, including less frequent GP contact and medications, and greater use of secondary healthcare. |
| Watson et al.[48] | England | 142,302 people living with dementia | Quantitative: Observational longitudinal study |
Social and spatial inequalities | People with rural GP practices had significantly fewer GP observations than urban (IRR: 0.909; 0.900 −0.919). In later-onset dementia, A&E attendances were more likely among people living with dementia with rural GPs (OR: 1.204; 1.156 −1.253), but emergency hospital admission spells were less likely (OR: 0.820; 0.787 −0.855). Compared to the Northeast GP region, people living with dementia registered with GPs in other regions had significantly fewer GP contacts but more non-dementia medications. |
| Watson et al.[46] | England | 142,340 people living with dementia with at least 2 years of post-diagnosis follow-up data | Quantitative: Observational longitudinal study |
Mortality risk | Compared to the Southeast Coast region, mortality risk was greater in the South Central (HR: 1.23; 1.17 −1.29), Southwest (HR: 1.17; 1.11 −1.23), Northeast (HR: 1.10; 1.03 −1.16) GP regions. |
| Wu et al.[49] | Great Britain | 1547 people with dementia and 1283 carers | Quantitative: Observational cross-sectional |
Living well with dementia | Mean scores for living well were similar across urban and rural areas. There was no substantial difference in living well indicators across urban and rural areas. |
| Yin et al.[50] | China | 161 counties and districts | Quantitative: Observational longitudinal study |
Dementia mortality | Mortality rates were significantly higher in the east (rate ratio 2.28) compared with the north. Dementia mortality decreased by 15 % in urban areas but increased by 24 % in rural areas. |
| Zakarias et al.[51] | Denmark | 5516 patients who had been diagnosed in 2015 | Quantitative: Observational cross-sectional |
Diagnostic quality | The age and sex-standardised national prevalence rate of registered dementia diagnoses was 3.0 %, ranging from 2.5 % to 3.6 % in the five regions. The proportion of patients who were registered with a specific dementia diagnosis at their first diagnosis varied from 45.3 % to 75.5 % in the regions. The proportion of patients diagnosed at a dementia specialist department ranged from 60.9 % to 90.5 % across the five regions. |