Global rural health disparities in Alzheimer's disease and related dementias: State of the science

The intersection of rurality and dementia prevalence in Australia for Aboriginal and Torres Strait Islander and non-Indigenous peoples

OBJECTIVES

To determine the nationwide prevalence of dementia as it intersects with rurality for Aboriginal and Torres Strait Islander and non-Indigenous peoples in Australia.

STUDY DESIGN

Cross-sectional population-based prevalence study using nationwide respondent-reported data.

SETTING, PARTICIPANTS

All people aged 45 years and older, including people living in residential aged care facilities, hospitals and prisons, who responded to the 2021 Australian census.

MAIN OUTCOME MEASURES

Crude, age-specific and age-standardised dementia prevalence, and odds of dementia, for Aboriginal and Torres Strait Islander and non-Indigenous peoples across remoteness levels.

RESULTS

For non-Indigenous peoples, the crude and age-standardised (World Health Organization standard) prevalence of dementia was 10.6 and 7.4 per 1000 persons, respectively. For Aboriginal and Torres Strait Islander peoples, the crude and age-standardised prevalence was 13.4 and 16.2 per 1000 persons, respectively. The age-specific prevalence ratio for Aboriginal and Torres Strait Islander and non-Indigenous peoples was most pronounced at younger age bands (3.5 for 45-49 years, 3.8 for 50-54 years and 3.4 for 60-64 years), narrowing to 1.6 among those aged 80-84 years. Odds of dementia decreased significantly with increasing remoteness for non-Indigenous peoples, but not for the Aboriginal and Torres Strait Islander population. Increasing age and no educational attainment were strongly associated with increased odds of dementia across both populations.

CONCLUSIONS

Consideration of geography is of crucial significance in dementia epidemiology, particularly for Aboriginal and Torres Strait Islander peoples. Our findings confirm those of previous community cohort and linked data studies that highlight the disproportionate burden of dementia borne by Aboriginal and Torres Strait Islander peoples using a national dataset. Place should inform targeted health care policy to address risk and protective factors for dementia prevention and care.

Editorial introduction to the special issue on biomarker-based diagnosis of Alzheimer's disease: A synthesis of the commentaries

We introduce a special issue of the Journal of Neuropsychology dedicated to a recent paradigm shift in Alzheimer's disease diagnosis. Joint workgroups from the (US) National Institute on Aging and the Alzheimer's Association (NIA-AA) recently issued policy guidelines reclassifying Alzheimer's disease as a biological entity. These guidelines shift the onus of diagnosis in favour of protein biomarkers, relegating cognitive symptoms (e.g. subjective memory and language disorders) as supportive rather than core features. We invited experts in the study of Alzheimer's disease and Related Disorders (ADRDs) to express their views on this paradigmatic shift in dementia management. In this editorial, we synthesize some of the main points advanced in the commentaries. Contributors identified the promise of blood-based biomarker testing for improving equitable detection of dementia in large swathes of the world population. This enthusiasm was tempered by concerns about the biomarker-only diagnostic approach, including the potential for significant harm (e.g. stigma, depression, suicide) caused by labelling asymptomatic older adults who might otherwise never behaviourally express the underlying disease pathology.

Clinical, biological, and neuroimaging profiles for motoric cognitive risk syndrome in older adults: The MIND-China study

BACKGROUND

Motoric cognitive risk syndrome (MCR) has been associated with dementia, functional dependence, and mortality. We sought to describe the prevalence and distribution of MCR and to explore the clinical, biological, and neuroimaging profiles for MCR in rural-dwelling Chinese older adults.

METHODS

This population-based study included 5021 dementia- and disability-free participants (mean age 70.3 years) in MIND-China. Of these, data were available in 1186 for blood biomarkers of Alzheimer's disease and vascular injury and in 1159 for structural brain magnetic resonance imaging biomarkers. MCR was defined as having both subjective memory complaints and gait speed ≥1 standard deviation below the age- and sex-specific means. Data were analyzed using logistic regression models and voxel-based morphometry methods.

RESULTS

The overall prevalence of MCR was 13.58%, which was higher in females than in males and increased with age. Controlling for demographic and lifestyle factors, obesity, diabetes, dyslipidemia, coronary heart disease, stroke, osteoarthritis, hip fracture, and depressive symptoms were significantly associated with an elevated likelihood of MCR (p < 0.05). MCR was significantly associated with smaller volumes of the total brain tissue, thalamus, hippocampus, cerebellum, insula, supplementary motor area, and inferior frontal gyrus, higher volumes of white matter hyperintensities, and an increased likelihood of lacunes (all p < 0.05), but not with any of the examined blood biomarkers (p > 0.05).

CONCLUSIONS

MCR affects approximately one-seventh of rural-dwelling Chinese older adults. The clinical and neuroimaging profiles for MCR are characterized by cardiometabolic disorders, osteoarthritis, hip fracture, and depressive symptoms as well as global and regional brain atrophy and cerebral microvascular lesions.

Effects of Medicare predictors in health disparities in the risk of Alzheimer's disease

INTRODUCTION

Disparities in Alzheimer's disease (AD) and related dementias (ADRD) persist across race/ethnicity, sex, and US geographic regions, but limited quantitative information exists to explain how specific predictors contribute to these disparities. Many traditional methods lack precision in addressing both exposure (higher prevalence of a predictor) and vulnerability (higher risk associated with a predictor) effects. This study introduces an approach that leverages population attributable fraction (PAF) to analyze and explain AD/ADRD disparities using Medicare data.

METHODS

We applied our method to Medicare claims data from a nationally representative sample of the US adults aged 70, 75, 80, and 85. The analysis focused on six types of disparities: Black-White, Hispanic-White, Native American-White, Asian-White, female-male, and stroke-belt versus non-stroke-belt states. Predictors included Medicare/Medicaid dual eligibility as an indicator of low income and 10 AD/ADRD-related diseases. The method quantified the exposure and vulnerability effects of each predictor on the observed disparities.

RESULTS

Low income and vulnerability to arterial hypertension were the primary contributors to AD/ADRD disparities, with cerebrovascular diseases and depression as notable secondary predictors. The exposure effect dominated for income-related disparities, while hypertension's effect was largely driven by increased vulnerability. Racial disparities (Black-White, Hispanic-White) were most affected by income and hypertension, while female-male and stroke-belt disparities were less influenced by the examined predictors.

DISCUSSION

Our findings indicate that different intervention strategies are needed to address AD/ADRD disparities. Income-related disparities require targeting exposure (e.g., socioeconomic improvements), while hypertension-related disparities suggest a focus on managing vulnerability (e.g., better control of hypertension). The developed approach offers a robust framework for explaining disparities and designing targeted interventions. Further application to other datasets and exploration of additional predictors could enhance understanding and lead to more effective prevention strategies for AD/ADRD disparities.

Highlights

Our new approach addresses disparities leveraging the concept of population attributable fraction for Cox models.Exposure and vulnerability mechanisms of health disparity generation are evaluated.Vulnerability to hypertension is a consistent dominant factor in Alzheimer's disease (AD) risk disparities.Predictors explain AD disparities better in Black and Hispanic populations.Disparities in AD are driven by exposure to socioeconomic status suggesting targeted interventions.

Equity of access in rural and metropolitan dementia diagnosis, management, and care experiences: an exploratory qualitative study

BACKGROUND

The limited allocation of resources to rural and regional communities is a major contributor to healthcare inequities in Australia. Distribution of health service resources between metropolitan and rural communities commonly sees highly populated areas prioritised over more sparsely populated and geographically vast areas. As such, challenges impacting dementia diagnosis, management, and care in metropolitan areas are experienced more acutely in rural areas. This study aimed to examine equity of access to dementia diagnosis, management, and care services amongst people who experienced the process of dementia diagnosis as a patient or significant other (partner/spouse, adult children, siblings, and friends) throughout rural and metropolitan Australia.

METHODS

This exploratory qualitative study consisted of thirty-three online semi-structured interviews with thirty-seven people with experience of the dementia diagnosis process as a patient and/or significant other. Interviews explored symptoms of dementia, health professionals consulted, tests conducted, and challenges faced throughout the diagnosis and post-diagnosis process. Rurality was defined by the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) and the Modified Monash Model (MMM). Thematic analysis was conducted, with Russell's (2013) Dimensions of Access framework (geography, affordability, availability, acceptability, accommodation, awareness, and timeliness) guiding data analysis.

RESULTS

Participants were distributed across various regions of Australia: seven interviews from inner regional Australia, five interviews from outer regional Australia, and twenty-one interviews from metropolitan areas. Disparities in access between metropolitan and rural areas emerged in five key dimensions: 1) geography impeding ability to access services; 2) affordability of travel expenses; 3) availability of healthcare and support services; 4) acceptability of available health professionals and services; and 5) awareness of local services and resources. The dimensions of accommodation and timeliness of care were experienced as challenges irrespective of location, with lengthy appointment wait times and difficulty navigating complex systems. However, rurality often compounded the challenges in dementia diagnosis, management, and care.

CONCLUSIONS

Significant health inequities persist between rural and metropolitan communities that must be prioritised in endeavours to promote equitable dementia diagnosis, management, and care. Targeted action to address disparities is vital to mitigate the impact of rurality, particularly as clinical practice evolves with research advancements.

Greater alcohol intake predicts accelerated brain aging in humans, which mediates the relationship between alcohol intake and behavioral inflexibility

BACKGROUND

Hazardous use of alcohol is associated with cognitive-behavioral impairments and accelerated aging. To date, however, accelerated brain aging has not been tested as a mediating factor between alcohol use and associated task-based behavioral deficits, such as behavioral inflexibility. Here, we evaluated hazardous alcohol use as a predictor of machine learning-derived brain aging and tested if this measure accounted for the relationship between hazardous alcohol use and a task-based measure of behavioral flexibility.

METHODS

In this secondary analysis, we applied brainageR, a machine learning algorithm, to anatomical T1-weighted magnetic resonance imaging (MRI) images to estimate brain age for a sample of healthy adults (ages 22-40) who self-reported alcohol use with the alcohol use disorder identification test (AUDIT) and performed the hidden association between images task (HABIT), a behavioral flexibility task. Behavioral inflexibility was quantified as the proportion of perseverative errors performed on the HABIT as a measure of habitual action selection. We then analyzed AUDIT score as a predictor of brain aging, and brain aging as a predictor of behavioral inflexibility. Lastly, we conducted a mediation analysis to evaluate brain aging as a mediator between alcohol use and behavioral inflexibility.

RESULTS

Controlling for chronological age and sex, a higher AUDIT score predicted significantly more accelerated brain aging, which was further associated with more perseverative errors on the HABIT. Moreover, brain aging significantly mediated the association between AUDIT scores and behavioral inflexibility.

CONCLUSIONS

Our findings demonstrate that alcohol use is a significant predictor of accelerated brain aging, even in young adulthood. In addition, our findings suggest that such brain changes may mechanistically link more hazardous alcohol use to impaired behavioral flexibility. Future studies should also explore factors, such as other lifestyle behaviors, that may mitigate alcohol- and age-related processes.

Estimated pulse wave velocity associated with cognitive phenotypes in a rural older population in China: A cohort study

INTRODUCTION

To examine the longitudinal association between estimated pulse wave velocity (ePWV) and cognitive phenotypes in a rural Chinese older population.

METHODS

This population-based study included 1857 dementia-free participants (age ≥60 years) who were examined in 2014 and followed in 2018. ePWV was calculated using age and mean blood pressure (MBP). Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and neuropsychological tests. Dementia was diagnosed following the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Data were analyzed using Cox proportional-hazards models, linear regression models, and restricted cubic spline (RCS) curves.

RESULTS

Per 1-m/s increase in ePWV was associated with an adjusted hazard ratio (HR) (95% confidence interval [CI]) of 1.51(1.30-1.75) for dementia and 1.58(1.33-1.89) for Alzheimer's disease (AD), and with an MMSE score decline (adjusted β-coefficient = -0.36; 95% CI = -0.52 to -0.21). A nonlinear association was observed between baseline ePWV and follow-up cognitive scores.

DISCUSSION

A higher ePWV is associated with an increased risk of dementia, AD, accelerated cognitive decline, and poorer cognitive performance in older adults.

HIGHLIGHTS

An increased estimated pulse wave velocity (ePWV) was associated with incident dementia, Alzheimer's disease, and accelerated cognitive decline in a rural Chinese older population. A higher ePWV at baseline was associated with lower scores of global cognition and multiple cognitive domains at the 4-year follow-up. An increased ePWV may be a risk factor for dementia and accelerated cognitive deterioration in aging.

Rural-urban disparities of Alzheimer's disease and related dementias: A scoping review

The rising age of the global population has made Alzheimer's disease and related dementias (ADRD) a critical public health problem, with significant health-related disparities observed between rural and urban areas. However, no previous reviews have examined the scope and determinant factors contributing to rural-urban disparities of ADRD-related health outcomes. This study aims to systematically collate and synthesize peer-reviewed articles on rural-urban disparities in ADRD, identifying key determinants and research gaps to guide future research. We conducted a systematic search using key terms related to rural-urban disparities and ADRD without restrictions on geography or study design. Five search engines-MEDLINE, CINAHL, Web of Science, PubMed, and Scopus-were used to identify relevant articles. The search was performed on August 16, 2024, and included English-language articles published from 2000 onward. Sixty-three articles met the eligibility criteria for data extraction and synthesis. Most articles were published after 2010 (85.7%) and were concentrated in the United States, China, and Canada (66.7%). A majority had cross-sectional (58.7%) or cohort study designs (23.8%), primarily examining prevalence (41.3%) or incidence (11.1%). Findings often indicated a higher prevalence and incidence in rural areas, although inconsistent rural-urban classification systems were noted. Common risk factors included female sex, lower education level, lower income, and comorbidities such as diabetes and cerebrovascular diseases. Environmental (12.7%) and lifestyle (14.3%) factors for ADRD have been less explored. The statistical methods used were mainly traditional analyses (e.g., logistic regression) and lacked advanced techniques such as machine learning or causal inference methods. The gaps identified in this review emphasize the need for future research in underexplored geographic regions and encourage the use of advanced methods to investigate understudied factors contributing to ADRD disparities, such as environmental, lifestyle, and genetic influences.

Highlights

Few studies on rural-urban ADRD disparities focus on low- and middle-income countries.Common risk factors include female sex, low education attainment, low income, and comorbidities.Inconsistent definitions of "rural" complicate cross-country comparisons.Environmental and lifestyle factors affecting ADRD are underexplored.Advanced statistical methods, such as machine learning and causal inference, are recommended.

Exploring social determinants of healthcare and cognition levels among diverse older adults

BACKGROUND

The purpose was to investigate the impact of social determinants of health on healthcare utilization among older adults in two cognition groups: normal and dementia/impaired cognition.

METHODS

We used cross-sectional data from the Health and Retirement Study (N = 16,339) to assess healthcare utilization: hospital stay, nursing home stay, hospice care, and doctor visits. The respondents were classified into two cognition groups using the Langa-Weir approach.

RESULTS

A cohort comparison between normal (mean age = 66.1) and dementia/impaired cognition (mean age = 71.9) groups revealed dementia/impaired group included more individuals from racial and ethnic minorities (42.7 % Black/Other, 20.8 % Hispanic) compared to the normal cognition (24.7 % Black/Other, 12.1 % Hispanic). They experienced longer hospital, nursing home, and hospice stays and varied doctor visit frequencies. These differences were influenced by race, age, marital status, education, and rurality.

CONCLUSION

Social determinants of health play an important role in predicting disparities in healthcare utilization among older adults across cognition levels.

Gaps in biomedical research in frontotemporal dementia: A call for diversity and disparities focused research

Frontotemporal dementia (FTD) is one of the leading causes of young-onset dementia before age 65, typically manifesting as abnormal behavior (in behavioral variant FTD) or language impairment (in primary progressive aphasia). Although FTD affects all populations across the globe, knowledge regarding the pathophysiology and genetics derives primarily from studies conducted in North America and Western Europe. Globally, biomedical research for FTD is hindered by variable access to diagnosis, discussed in this group's earlier article, and by reduced access to expertise, funding, and infrastructure. This perspective paper was produced by two professional interest areas of the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) and discusses the field's current status on the cross-cultural aspects of basic and translational research in FTD (including that focused on epidemiology, genetics, biomarkers, and treatment). It subsequently provides a summary of gaps and needs to address the disparities and advance global FTD biomedical research.

Prevalence of dementia among Indigenous populations of countries with a very high Human Development Index: a systematic review

Dementia is a health priority for Indigenous peoples. Here, we reviewed studies on the prevalence of dementia or cognitive impairment among Indigenous populations from countries with a very high Human Development Index (≥0·8). Quality was assessed using the Joanna Briggs Institute risk-of-bias tool and CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples (CONSIDER), with oversight provided by an Indigenous Advisory Board. After screening, 23 studies were included in the Review. Relative to the respective non-Indigenous populations, greater age-standardised prevalence ratios were observed in the Australian Aboriginal and Torres Strait Islander (2·5-5·2), Aotearoa-New Zealand Māori (1·2-2·0), and Singaporean Malay (1·3-1·7) populations, and greater crude prevalence ratios were observed in the Canadian First Nation (1·3), Singaporean Malay (2·3), Malaysian Melanau (1·7-4·0), American Indian and Alaska Native (1·0-3·2), and Chamorro of Guam (1·2-2·0) populations. The prevalence ratios were greater across younger age groups, predominantly comprising those younger than 70 years. 14 studies presented a moderate risk of bias and few studies reported Indigenous involvement. Despite improved management of risk factors, a greater prevalence of dementia persists in Indigenous populations, overall and at younger ages than in non-Indigenous populations. Future epidemiological work involving Indigenous populations should uphold and prioritise Indigenous perspectives.

Association of dementia with impaired kidney function and plasma biomarkers: A population-based study

BACKGROUND AND PURPOSE

Emerging evidence has linked impaired kidney function with dementia in older adults, but the neuropathological pathways underlying their association remain poorly understood. We sought to examine the relationships of kidney function with dementia and plasma biomarkers in a Chinese rural population.

METHODS

This population-based study used data from the baseline examination of the Multimodal Interventions to Delay Dementia and Disability in rural China (MIND-China) cohort (March-September 2018; n = 5715). Kidney function was assessed using estimated glomerular filtration rate (eGFR) based on serum creatinine level. Dementia, Alzheimer's disease (AD) and vascular dementia (VaD) were diagnosed according to the international criteria. Plasma biomarkers were measured using the SIMOA platform in a subsample (n = 1446). Data were analyzed using logistic, general linear, and mediation models.

RESULTS

Of the 5715 participants, 306 were diagnosed with dementia, including 195 with AD and 100 with VaD. Impaired kidney function (eGFR <60 vs. ≥90 mL/min/1.73 m2) was associated with multivariable-adjusted odds ratios of 2.24 (95% confidence interval [CI] 1.44-3.46) for all-cause dementia, 1.85 (1.07-3.18) for AD, and 2.49 (1.16-5.22) for VaD. In the biomarker subsample, impaired kidney function was significantly associated with higher plasma amyloid-β (Aβ)40 (β-coefficient = 54.36, 95% CI 43.34-65.39), Aβ42 (β-coefficient = 3.14, 95% CI 2.42-3.86), neurofilament light chain (β-coefficient = 10.62, 95% CI 5.62-15.62), and total tau (β-coefficient = 0.68, 95% CI 0.44-0.91), and a lower Aβ42/Aβ40 ratio (β-coefficient = -4.11, 95% CI -8.08 to -0.14). The mediation analysis showed that plasma total tau significantly mediated 21.76% of the association between impaired kidney function and AD (p < 0.05).

CONCLUSION

Impaired kidney function is associated with dementia and plasma biomarkers among rural-dwelling older Chinese adults, and the association with AD is partly mediated by plasma biomarkers for neurodegeneration.

Representing the Needs of Rural Caregivers of People Living With Alzheimer's Disease and Related Dementias Through User Personas

Background and Objectives

Rural caregivers of people living with Alzheimer's disease and related dementias (ADRD) face unique caregiving challenges. Current interventions do not address many of the systemic barriers experienced by rural ADRD caregivers, including barriers related to geography, healthcare services access, and financial insecurity. The objective of this study was to gain a deeper understanding of rural ADRD caregivers' needs, strengths, and strategies in obtaining caregiving support, and to represent these attributes in the form of personas that can be used to design interventions for rural ADRD caregivers.

Research Design and Methods

In this qualitative user-centered design study, we conducted semistructured interviews with self-identified caregivers of people living with ADRD in rural areas. Interview data was copied to a virtual whiteboard, and affinity diagramming was used to confirm a priori attributes and yield inductive attributes relevant to rural ADRD caregivers. Attributes were assigned to personas, which were then validated through team-based discussion, consultation with a study advisory board, and review by rural caregivers and community partners.

Results

Analyses of N = 19 interviews yielded 7 inductive attributes relevant to rural ADRD caregivers of persons living with ADRD and 5 distinct personas: Capable Christine, Connected Connie, Isolated Irene, Learning Larry, and Discerning Dan. Personas differed on inductive attributes including financial security, subjective rurality, attitudes, connectedness, and information behavior, including preferences for traditional versus technology-based information seeking.

Discussion and Implications

The personas identified in the present study can be used as tools to represent and efficiently communicate the intersection and interaction of attributes relevant to designing interventions and technologies to meet the support needs of rural ADRD caregivers.

Disparities in structural brain imaging in older adults from rural communities in Southern Nevada

Introduction

Identifying the associations between rural-living or neighborhood disadvantage and neurobiology may clarify rural-urban disparities in older adults with cognitive impairment related to Alzheimer's disease.

Methods

We examined rural-urban differences and neighborhood disadvantages in brain cortical thickness (CT) measures among 71 rural and 87 urban-dwelling older adults. Analysis of covariance was used to test each FreeSurfer-derived CT measures' associations with rural-urban living, clinical impairment status, and their interactions. Post-hoc linear regressions were used to test the association between CT measures and neighborhood disadvantage index.

Results

Rural-dwelling older adults had thinner cortices in temporal and inferior frontal regions compared to urban participants, especially among clinically normal participants, where the thinner temporal cortex further correlated with higher neighborhood disadvantage. Conversely, rural participants had thicker cortices in superior frontal, parietal and occipital regions.

Discussion

Our results suggest a complex interplay between community contexts and neurobiology. For memory-related regions, rural-living and neighborhood disadvantage might be negatively associated with subjects' brain structures.

The lifestyle for brain health index, the cluster of differentiation 33 (CD33) gene, and cognitive function among rural Chinese older adults: A population-based study

BACKGROUND

We sought to examine the associations of the Lifestyle for Brain Health (LIBRA) index with cognitive function among rural Chinese older adults and to explore the potential role of cluster of differentiation 33 gene (CD33) in the associations.

METHODS

This population-based cross-sectional study included 4914 dementia-free participants (age ≥60 years; 56.43 % women) in the 2018 baseline examination of MIND-China. The LIBRA index was generated from 11 factors. We used a neuropsychological test battery to assess episodic memory, verbal fluency, attention, executive function, and global cognition. The CD33(rs3865444) polymorphism was detected using multiple-polymerase chain reaction amplification. Data were analyzed using the general linear regression models.

RESULTS

A higher LIBRA index was associated with multivariable-adjusted β-coefficient (95 %CI) of -0.011(-0.020- -0.001) for global cognitive z-score, -0.020(-0.033- -0.006) for episodic memory, and -0.016(-0.029- -0.004) for verbal fluency. The CD33(rs3865444) was associated with a lower global cognitive z-score in the additive (CA vs. CC: β-coefficient=0.042; 95 %CI=0.008-0.077), the dominant (CA+AA vs. CC: 0.040; 0.007-0.073), and the over-dominant (CA vs. CC+AA: 0.043; 0.009-0.077) models. Similar results were obtained for verbal fluency and attention. The CD33 gene showed statistical interactions with LIBRA index on cognitive function (Pinteraction<0.05) such that a higher LIBRA index was significantly associated with lower z-scores of global cognition and attention only among CD33 CC carriers (P < 0.05).

CONCLUSIONS

This population-based study reveals for the first time that a higher LIBRA index is associated with worse cognitive performance in rural Chinese older adults and that CD33 gene could modify the association.

Association of polygenic risk scores with Alzheimer's disease and plasma biomarkers among Chinese older adults: A community-based study

INTRODUCTION

We examined the associations of polygenic risk score (PRS) with Alzheimer's disease (AD) and plasma biomarkers in the Chinese population.

METHODS

This population-based study used baseline data from MIND-China (2018; n = 4873) and follow-up data from dementia-free individuals (2014-2018; n = 2117). We measured AD-related plasma biomarkers in a subsample (n = 1256). Data were analyzed using logistic and Cox regression models.

RESULTS

We developed PRS with (PRSAPOE) and without (PRSnon- APOE) apolipoprotein E (APOE) gene. In the longitudinal analysis, PRSAPOE was associated with a multivariable-adjusted hazards ratio of 1.91 (95% CI = 1.13-3.23) for AD. PRSAPOE in combination with demographics yielded discriminative (area under the curve [AUC]) and predictive(C-statistic) accuracy of 0.80 (95% confidence interval [CI] = 0.77-0.84) and 0.80 (0.77-0.82), respectively. PRSnon- APOE showed an association with AD risk similar to PRSAPOE. PRSAPOE, but not PRSnon- APOE, was associated with reduced plasma Aβ42/Aβ40 ratio and increased Neurofilament light chain (NfL) (p < 0.05).

DISCUSSION

The PRS with and without APOE gene, in combination with demographics, shows good discriminative and predictive ability for AD. The AD-related pathologies underlie AD risk associated with PRSAPOE.

HIGHLIGHTS

The PRSAPOE and PRSnon- APOE were associated with AD risk in the Chinese population. The PRSAPOE and PRSnon- APOE, in combination with demographics, showed good discriminative and predictive ability for AD. The AD-related pathologies underlie the AD risk associated with PRSAPOE but not PRSnon- APOE.

Cardiometabolic multimorbidity, peripheral biomarkers, and dementia in rural older adults: The MIND-China study

INTRODUCTION

Evidence has emerged that cardiometabolic multimorbidity (CMM) is associated with dementia, but the underlying mechanisms are poorly understood.

METHODS

This population-based study included 5704 older adults. Of these, data were available in 1439 persons for plasma amyloid-β (Aβ), total tau, and neurofilament light chain (NfL) and in 1809 persons for serum cytokines. We defined CMM following two common definitions used in previous studies. Data were analyzed using general linear, logistic, and mediation models.

RESULTS

The presence of CMM was significantly associated with an increased likelihood of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) (p < 0.05). CMM was significantly associated with increased plasma Aβ40, Aβ42, and NfL, whereas CMM that included visceral obesity was associated with increased serum cytokines. The mediation analysis suggested that plasma NfL significantly mediated the association of CMM with AD.

DISCUSSION

CMM is associated with dementia, AD, and VaD in older adults. The neurodegenerative pathway is involved in the association of CMM with AD.

HIGHLIGHTS

The presence of CMM was associated with increased likelihoods of dementia, AD, and VaD in older adults. CMM was associated with increased AD-related plasma biomarkers and serum inflammatory cytokines. Neurodegenerative pathway was partly involved in the association of CMM with AD.

Association Between the Average Number of In-Network Hospitals and Medical Counseling for Cognitive Impairment in South Korea

OBJECTIVES

Mild cognitive impairment, a pressing concern in the face of a rapidly growing global older adult population, necessitates effective management strategies focused on sustained symptom relief and preventing deterioration. Community Dementia Care Centers, in partnership with in-network hospitals, aim to provide support for preventing mild cognitive impairment and dementia. Medical counseling, influenced by in-network hospitals, is crucial for tailoring interventions to the cognitive abilities and specific needs of each older adult, protecting against dementia. Disparities in the number of in-network hospitals and healthcare infrastructure can contribute to uneven access to dementia care, thereby creating health inequities.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Using data from the Korea Community Health Survey (2018-2019), this study focused on South Korean individuals aged 60 and older in 17 metropolitan areas and provinces.

METHODS

A multiple regression analysis was used to examine the relationship between the average number of in-network hospitals and medical counseling experience, considering sociodemographic factors and related variables.

RESULTS

Areas with a higher average number of in-network hospitals exhibited increased medical counseling experiences. Significantly higher odds for medical counseling experience were observed in regions with "more than 5 hospitals" (1.36; 95% CI, 1.20-1.54; P = .000) than those with "3 or fewer hospitals."

CONCLUSIONS AND IMPLICATIONS

This study underscores the importance of infrastructure, particularly collaborative hospitals that support Community Dementia Care Centers, in influencing individual dementia management and prevention. These findings highlight the significance of dementia prevention and management infrastructures, emphasizing the need for practical assistance, particularly in regions crucial for achieving health equity.

Association between the incident hypertension duration and cognitive performance in older adults: data from the NHANES 2011-2014

BACKGROUND

Established evidences have demonstrated that hypertension was associated with the cognitive impairment. But the associations between the duration of hypertension exposure and cognitive performance are still inconclusive.

OBJECTIVES

The objective of this study was to assess the association between the duration of hypertension diagnosis and cognitive performance in older adults by the National Health and Nutrition Examination Survey (2011-2014).

METHODS

To evaluate the relationship between the hypertension duration and cognitive performance, we conducted the logistic regression analysis. Furthermore, we also performed the Restricted cubic spline (RCS) analysis to assess the nonlinear relationship between the duration of exposure to hypertension and cognitive performance.

RESULTS

Initially, total 19,931 participants were included in this study, and 2928 individuals were enrolled. With the increase of hypertension duration, more risk of cognitive impairment was observed in the Digit Symbol Substitution test (DSST) (OR = 1.012, 1.006-1.019), and a similar trend was observed in Animal Fluency test (AFT) (OR = 1.009,1.003-1.016). The RCS results showed that the hypertension duration pattern was linear associated with the risk of cognitive impairment in DDST (P for non-linearity = 0.758). Meanwhile, subgroups analysis of midlife hypertension, we revealed that linear association with the risk of cognitive impairment in DSST (P for non-linearity = 0.391) and CERAD (P for non-linearity = 0.849) among hypertension diagnose < 55 years populations.

CONCLUSION

Collectively, our finding indicates that longer duration of exposure to hypertension worsens the cognition performance, especially for middle-aged hypertension.

Trends on Prevalence, All-Cause Mortality, and Survival Status of Dementia Patients in Rural China Based on Pooling Analysis

Objectives

No study has reported secular trends in dementia prevalence, all-cause mortality, and survival status in rural China.

Methods

We established two cohorts (XRRCC1 and XRRCC2) in the same region of China, 17 years apart, to compare dementia prevalence, all-cause mortality, and survival status, and performed regression analysis to identify associated factors.

Results

Dementia prevalence was 3.49% in XRRCC1 and 4.25% in XRRCC2, with XRRCC2 showing a significantly higher prevalence (OR = 1.79, 95%CI: 1.2-2.65). All-cause mortality rates for dementia patients were 62.0% in XRRCC1 and 35.7% in XRRCC2. Mortality in the normal population of XRRCC2 decreased by 66% compared to XRRCC1, mainly due to improved survival rates in women with dementia. Dementia prevalence was positively associated with age >65, spouse-absent status, and stroke, and negatively associated with ≥6 years of education.

Conclusion

Dementia prevalence in rural China increased over 17 years, while mortality decreased. Major risk factors include aging, no spouse, and stroke, with higher education offering some protection.

The Best of Two Worlds to Promote Healthy Cognitive Aging: Definition and Classification Approach of Hybrid Physical Training Interventions

A healthy lifestyle can be an important prerequisite to prevent or at least delay the onset of dementia. However, the large number of physically inactive adults underscores the need for developing and evaluating intervention approaches aimed at improving adherence to a physically active lifestyle. In this regard, hybrid physical training, which usually combines center- and home-based physical exercise sessions and has proven successful in rehabilitative settings, could offer a promising approach to preserving cognitive health in the aging population. Despite its potential, research in this area is limited as hybrid physical training interventions have been underused in promoting healthy cognitive aging. Furthermore, the absence of a universally accepted definition or a classification framework for hybrid physical training interventions poses a challenge to future progress in this direction. To address this gap, this article informs the reader about hybrid physical training by providing a definition and classification approach of different types, discussing their specific advantages and disadvantages, and offering recommendations for future research. Specifically, we focus on applying digital technologies to deliver home-based exercises, as their use holds significant potential for reaching underserved and marginalized groups, such as older adults with mobility impairments living in rural areas.

Social Determinants of Health and Healthcare Utilization Disparities among Older Adults with and Without Cognitive Impairment

The purpose of this study was to determine the healthcare utilization patterns in a national sample of older adults across several social determinants of health factors (ethnicity, gender, race, education) with normal and dementia/impaired cognition. We used datasets from the Health and Retirement Study (HRS, 2018) to evaluate healthcare utilization, including metrics such as hospital and nursing home stays, hospice care, and number of visits to the doctor. Logistic models were used to predict healthcare utilization separately in those with normal cognition and dementia. Our final sample comprised 15,607 adults (mean age: 65.2 normal cognition, mean age 71.5 dementia). Hispanics with normal cognition were less likely to stay in a hospital than non-Hispanic respondents (OR: 0.52-0.71, p<0.01). Being female was associated with a higher risk for shorter nursing home days (OR: 1.41, p<0.01) and doctor visits (OR: 1.63-2, p<0.01) in cognitively normal older adults. Being female was associated with a lower risk for hospital stay in those with dementia (OR: 0.50-0.78, p<0.01). Respondents identifying as Black or other races with dementia were less likely to experience nursing home days (OR: 0.42, p<0.04). Black respondents with normal cognition were less likely to experience doctor visits (OR: 0.32-0.37, p<0.01). Those with more than a high school education in both groups were more likely to experience doctors' visits. The study points to the continued disparities in healthcare utilization linked to participants' social determinants of health factors and cognition.

Diabetes accelerates Alzheimer's disease progression in the first year post mild cognitive impairment diagnosis

BACKGROUND

Mild cognitive impairment (MCI) heightens Alzheimer's disease (AD) risk, with diabetes mellitus (DM) potentially exacerbating this vulnerability. This study identifies the optimal intervention period and neurobiological targets in MCI to AD progression using the Alzheimer's Disease Neuroimaging Initiative dataset.

METHODS

Analysis of 980 MCI patients, categorized by DM status, used propensity score matching and inverse probability treatment weighting to assess rate of conversion from MCI to AD, neuroimaging, and cognitive changes.

RESULTS

DM significantly correlates with cognitive decline and an increased risk of progressing to AD, especially within the first year of MCI follow-up. It adversely affects specific brain structures, notably accelerating nucleus accumbens atrophy, decreasing gray matter volume and sulcal depth.

DISCUSSION

Findings suggest the first year after MCI diagnosis as the critical window for intervention. DM accelerates MCI-to-AD progression, targeting specific brain areas, underscoring the need for early therapeutic intervention.

HIGHLIGHTS

Diabetes mellitus (DM) accelerates mild cognitive impairment (MCI)-to-Alzheimer's disease (AD) progression within the first year after MCI diagnosis. DM leads to sharper cognitive decline within 12 months of follow-up. There is notable nucleus accumbens atrophy observed in MCI patients with DM. DM causes significant reductions in gray matter volume and sulcal depth. There are stronger correlations between cognitive decline and brain changes due to DM.

Alzheimer's disease pathophysiology in the Retina

The retina is an emerging CNS target for potential noninvasive diagnosis and tracking of Alzheimer's disease (AD). Studies have identified the pathological hallmarks of AD, including amyloid β-protein (Aβ) deposits and abnormal tau protein isoforms, in the retinas of AD patients and animal models. Moreover, structural and functional vascular abnormalities such as reduced blood flow, vascular Aβ deposition, and blood-retinal barrier damage, along with inflammation and neurodegeneration, have been described in retinas of patients with mild cognitive impairment and AD dementia. Histological, biochemical, and clinical studies have demonstrated that the nature and severity of AD pathologies in the retina and brain correspond. Proteomics analysis revealed a similar pattern of dysregulated proteins and biological pathways in the retina and brain of AD patients, with enhanced inflammatory and neurodegenerative processes, impaired oxidative-phosphorylation, and mitochondrial dysfunction. Notably, investigational imaging technologies can now detect AD-specific amyloid deposits, as well as vasculopathy and neurodegeneration in the retina of living AD patients, suggesting alterations at different disease stages and links to brain pathology. Current and exploratory ophthalmic imaging modalities, such as optical coherence tomography (OCT), OCT-angiography, confocal scanning laser ophthalmoscopy, and hyperspectral imaging, may offer promise in the clinical assessment of AD. However, further research is needed to deepen our understanding of AD's impact on the retina and its progression. To advance this field, future studies require replication in larger and diverse cohorts with confirmed AD biomarkers and standardized retinal imaging techniques. This will validate potential retinal biomarkers for AD, aiding in early screening and monitoring.

Healthcare Disparities Among Older Adults: Exploring Social Determinants of Health and Cognition Levels

Background

The purpose was to investigate the impact of sociodemographic factors on healthcare utilization among adults with different cognition levels (normal and impairment/dementia).

Methods

We used cross-sectional data from the Health and Retirement Study (N=17,698) to assess healthcare utilization: hospital stay, nursing home stay, hospice care, and doctor visits.

Results

A cohort comparison between normal and dementia/impaired cognition groups revealed significant differences. The dementia/impaired group had lower education levels, higher single/widowed status, and more racial and ethnic minorities. They experienced longer hospital and nursing home stays, varied doctor visit frequencies, and had higher mean age, greater loneliness scores, and lower family social support scores. Differences in hospitalization, nursing home, hospice care, and doctor visits were influenced by factors such as race, age, marital status, education, and rurality.

Conclusion

There were disparities in healthcare utilization based on participants' characteristics and cognition levels, especially in terms of race/ethnicity, education, and rural location.

Association of enlarged perivascular spaces with cognitive function in dementia-free older adults: A population-based study

Introduction

We sought to characterize cognitive profiles associated with enlarged perivascular spaces (EPVS) among Chinese older adults.

Methods

This population-based study included 1191 dementia-free participants (age ≥60 years) in the MIND-China MRI Substudy (2018-2020). We visually evaluated EPVS in basal ganglia (BG) and centrum semiovale (CSO), white matter hyperintensities (WMHs), lacunes, cerebral microbleeds (CMBs), and cortical superficial siderosis. We used a neuropsychological test battery to assess cognitive function. Data were analyzed using general linear models.

Results

Greater BG-EPVS load was associated with lower z-scores in memory, verbal fluency, and global cognition (p < 0.05); these associations became non-significant when controlling for other cerebral small vessel disease (CSVD) markers (e.g., WMHs, lacunes, and mixed CMBs). Overall, CSO-EPVS load was not associated with cognitive z-scores (p > 0.05); among apolipoprotein E (APOE) -ε4 carriers, greater CSO-EPVS load was associated with lower verbal fluency z-score, even when controlling for other CSVD markers (p < 0.05).

Discussion

The associations of BG-EPVS with poor cognitive function in older adults are largely attributable to other CSVD markers.

HIGHLIGHTS

The association of enlarged perivascular spaces (EPVS) with cognitive function in older people is poorly defined.The association of basal ganglia (BG)-EPVS with poor cognition is attributed to other cerebral small vessel disease (CSVD) markers.In apolipoprotein E (APOE) ε4 carriers, a higher centrum semiovale (CSO)-EPVS load is associated with poorer verbal fluency.

Testing the 'Faith Moves Mountains model' to increase Alzheimer's disease awareness, detection, and diagnosis among rural, racially, and ethnically diverse older adults

OBJECTIVES

Racially and ethnically diverse populations have recently contributed to the majority of rural and small-town growth. Consequently, the disproportionately high risk and prevalence of Alzheimer's disease and related dementias (ADRD) among rural and minoritized older residents will likely increase. To address this threat, we tested the hypotheses that (1) a faith-based, resident-led approach would increase basic ADRD knowledge and diagnosis, and (2) older age, female gender, lower educational levels, and more years lived rural would predict number of referrals, new dementia diagnoses, and treatment.

METHODS

An adaptation of Schoenberg's Faith Moves Mountains model, previously successful in detection and management of other chronic illnesses in rural settings, guided this community-based participatory research. Local faith community members were trained as research assistants to recruit, administer surveys, conduct brief memory assessments, teach brain health strategies, and follow-up with residents. Outreaches were offered virtually during the pandemic, then in-person monthly at rotating church sites, and repeated ∼1 year later.

RESULTS

This rural sample was racially and ethnically diverse (74.5% non-White), with 28% reporting eight or less years of formal education. Findings included that referrals and years lived rural were significant and positive predictors of new ADRD treatments [(b = 3.74, χ2(1, n = 235) = 13.01, p < 0.001); (b = 0.02, χ2(1, n = 235 = 3.93, p = 0.048)], respectively, regardless of participant characteristics.

CONCLUSION

Resident-led action research in rural, diverse, faith communities is a successful approach to increasing ADRD disease knowledge, detection, diagnosis, and treatment.

Alcohol Use Disorder and Dementia: A Review

PURPOSE

By 2040, 21.6% of Americans will be over age 65, and the population of those older than age 85 is estimated to reach 14.4 million. Although not causative, older age is a risk factor for dementia: every 5 years beyond age 65, the risk doubles; approximately one-third of those older than age 85 are diagnosed with dementia. As current alcohol consumption among older adults is significantly higher compared to previous generations, a pressing question is whether drinking alcohol increases the risk for Alzheimer's disease or other forms of dementia.

SEARCH METHODS

Databases explored included PubMed, Web of Science, and ScienceDirect. To accomplish this narrative review on the effects of alcohol consumption on dementia risk, the literature covered included clinical diagnoses, epidemiology, neuropsychology, postmortem pathology, neuroimaging and other biomarkers, and translational studies. Searches conducted between January 12 and August 1, 2023, included the following terms and combinations: "aging," "alcoholism," "alcohol use disorder (AUD)," "brain," "CNS," "dementia," "Wernicke," "Korsakoff," "Alzheimer," "vascular," "frontotemporal," "Lewy body," "clinical," "diagnosis," "epidemiology," "pathology," "autopsy," "postmortem," "histology," "cognitive," "motor," "neuropsychological," "magnetic resonance," "imaging," "PET," "ligand," "degeneration," "atrophy," "translational," "rodent," "rat," "mouse," "model," "amyloid," "neurofibrillary tangles," "α-synuclein," or "presenilin." When relevant, "species" (i.e., "humans" or "other animals") was selected as an additional filter. Review articles were avoided when possible.

SEARCH RESULTS

The two terms "alcoholism" and "aging" retrieved about 1,350 papers; adding phrases-for example, "postmortem" or "magnetic resonance"-limited the number to fewer than 100 papers. Using the traditional term, "alcoholism" with "dementia" resulted in 876 citations, but using the currently accepted term "alcohol use disorder (AUD)" with "dementia" produced only 87 papers. Similarly, whereas the terms "Alzheimer's" and "alcoholism" yielded 318 results, "Alzheimer's" and "alcohol use disorder (AUD)" returned only 40 citations. As pertinent postmortem pathology papers were published in the 1950s and recent animal models of Alzheimer's disease were created in the early 2000s, articles referenced span the years 1957 to 2024. In total, more than 5,000 articles were considered; about 400 are herein referenced.

DISCUSSION AND CONCLUSIONS

Chronic alcohol misuse accelerates brain aging and contributes to cognitive impairments, including those in the mnemonic domain. The consensus among studies from multiple disciplines, however, is that alcohol misuse can increase the risk for dementia, but not necessarily Alzheimer's disease. Key issues to consider include the reversibility of brain damage following abstinence from chronic alcohol misuse compared to the degenerative and progressive course of Alzheimer's disease, and the characteristic presence of protein inclusions in the brains of people with Alzheimer's disease, which are absent in the brains of those with AUD.

Association of objective sleep duration with cognition and brain aging biomarkers in older adults

The neuropathological mechanisms underlying the association between sleep duration and mild cognitive impairment remain poorly understood. This population-based study included 2032 dementia-free people (age ≥ 60 years; 55.1% women) derived from participants in the Multimodal Interventions to Delay Dementia and Disability in Rural China; of these, data were available in 841 participants for Alzheimer's plasma biomarkers (e.g. amyloid-β, total tau and neurofilament light chain), 1044 for serum microvascular biomarkers (e.g. soluble adhesion molecules) and 834 for brain MRI biomarkers (e.g. whiter matter, grey matter, hippocampus, lacunes, enlarged perivascular spaces and white matter hyperintensity WMH). We used electrocardiogram-based cardiopulmonary coupling analysis to measure sleep duration, a neuropsychological test battery to assess cognitive function and the Petersen's criteria to define mild cognitive impairment. Data were analysed with multivariable logistic and general linear models. In the total sample (n = 2032), 510 participants were defined with mild cognitive impairment, including 438 with amnestic mild cognitive impairment and 72 with non-amnestic mild cognitive impairment. Long sleep duration (>8 versus 6-8 h) was significantly associated with increased likelihoods of mild cognitive impairment and non-amnestic mild cognitive impairment and lower scores in global cognition, verbal fluency, attention and executive function (Bonferroni-corrected P < 0.05). In the subsamples, long sleep duration was associated with higher plasma amyloid-β40 and total tau, a lower amyloid-β42/amyloid-β40 ratio and smaller grey matter volume (Bonferroni-corrected P < 0.05). Sleep duration was not significantly associated with serum-soluble adhesion molecules, white matter hyperintensity volume, global enlarged perivascular spaces and lacunes (P > 0.05). Alzheimer's and neurodegenerative pathologies may represent common pathways linking long sleep duration with mild cognitive impairment and low cognition in older adults.

Multimorbidity, cognitive phenotypes, and Alzheimer's disease plasma biomarkers in older adults: A population-based study

INTRODUCTION

To examine the burden and clusters of multimorbidity in association with mild cognitive impairment (MCI), dementia, and Alzheimer's disease (AD)-related plasma biomarkers among older adults.

METHODS

This population-based study included 5432 participants (age ≥60 years); of these, plasma amyloid beta (Aβ), total tau, and neurofilament light chain (NfL) were measured in a subsample (n = 1412). We used hierarchical clustering to generate five multimorbidity clusters from 23 chronic diseases. We diagnosed dementia and MCI following international criteria. Data were analyzed using logistic and linear regression models.

RESULTS

The number of chronic diseases was associated with dementia (multivariable-adjusted odds ratio = 1.22; 95% confidence interval [CI] = 1.11 to 1.33), AD (1.13; 1.01 to 1.26), vascular dementia (VaD) (1.44; 1.25 to 1.64), and non-amnestic MCI (1.25; 1.13 to 1.37). Metabolic cluster was associated with VaD and non-amnestic MCI, whereas degenerative ocular cluster was associated with AD (p < 0.05). The number of chronic diseases was associated with increased plasma Aβ and NfL (p < 0.05).

DISCUSSION

Multimorbidity burden and clusters are differentially associated with subtypes of dementia and MCI and AD-related plasma biomarkers in older adults.

HIGHLIGHTS

We used hierarchical clustering to generate five clusters of multimorbidity. The presence and load of multimorbidity were associated with dementia and mild cognitive impairment. Multimorbidity clusters were differentially associated with subtypes of dementia and Alzheimer's disease plasma biomarkers.

Pangenomics: A new era in the field of neurodegenerative diseases

A pangenome is composed of all the genetic variability of a group of individuals, and its application to the study of neurodegenerative diseases may provide valuable insights into the underlying aspects of genetic heterogenetiy for these complex ailments, including gene expression, epigenetics, and translation mechanisms. Furthermore, a reference pangenome allows for the identification of previously undetected structural commonalities and differences among individuals, which may help in the diagnosis of a disease, support the prediction of what will happen over time (prognosis) and aid in developing novel treatments in the perspective of personalized medicine. Therefore, in the present review, the application of the pangenome concept to the study of neurodegenerative diseases will be discussed and analyzed for its potential to enable an improvement in diagnosis and prognosis for these illnesses, leading to the development of tailored treatments for individual patients from the knowledge of the genomic composition of a whole population.

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

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.