Urban–rural disparities in dementia-related mortality among older adults in the U.S. from 1999 to 2020

Dementia, including Alzheimer’s disease and related dementias (ADRD), is a major cause of death among older adults in the United States. However, limited data exist on how dementia-related mortality patterns vary across urban and rural settings. This study aimed to examine national trends in dementia-related mortality from 1999 to 2020, with a focus on geographic disparities and differences in place of death. We analyzed mortality data from the CDC WONDER Multiple Cause of Death database for U.S. adults aged ≥65 years. Dementia-related deaths were identified using ICD-10 codes F01, F03, and G30. Age-adjusted mortality rates (AAMRs) per 100,000 were calculated using the 2000 U.S. standard population. Trends were assessed using joinpoint regression to estimate annual percent change (APC). Urbanization was classified using the 2013 NCHS Urban–Rural scheme. The place of death was examined by urban and rural residence. From 1999 to 2020, 6516,402 dementia-related deaths were recorded. The AAMR nearly doubled, increasing from 434.9 to 855.1 per 100,000. Females had higher AAMRs (from 444.5 to 905.9) than males (from 405.7 to 767.4). The steepest rise occurred in noncore rural counties (APC: 2.02 %; p < 0.001), while large central metropolitan areas showed slower growth (APC: 0.57 %). In rural areas, 61.8 % of dementia deaths occurred in nursing homes compared to 53.9 % in urban areas. Hospice facility deaths were less common in rural regions (2.1 % vs. 4.6 %), and home deaths were slightly lower (15.0 % vs. 18.6 %). Disparities persisted across age and racial/ethnic groups, with the oldest-old (≥85) and rural Black and White adults bearing the greatest burden. Dementia-related mortality has increased significantly over two decades, with disproportionately higher rates and institutional deaths in rural communities. These findings call for targeted interventions to reduce geographic disparities in dementia care and end-of-life services.