Rural–Urban Differences in Cognitive Outcomes Among Older Adults: The Roles of Falls and Depressive Symptoms

Background: Older adults with Alzheimer’s Disease and Related Dementias (ADRD) experience a higher risk of falls. However, research lacks evidence on the effect of fall exposure on cognitive impairment and dementia. We investigated the association of falls and depressive symptoms with cognitive impairment and dementia in a nationally representative sample. Methods: We analyzed data from 6221 participants (age ≥ 65) in the Health and Retirement Study (HRS) from the 2018–2020 waves, using Multinomial logistic regression models. Measures included the HRS health status questionnaire, HRS cognition scale, and the Center for Epidemiological Studies Depression scale. Results: Prevalence of fall exposure across cognition levels was 44.61% for dementia, 37.76% for cognitive impairment, and 32.16% for normal cognition. Having at least one fall exposure in the last 24 months significantly increased odds of having dementia by 42%, while the relationship between fall exposure and cognitive impairment was non-significant. Depressive symptoms were also associated with cognitive impairment and dementia. The stratified analysis by residential areas revealed that having a fall exposure increased the likelihood of having cognitive impairment by 26% and dementia by 73% in urban residents. However, the association between fall exposure and cognitive outcomes was not significant in rural settings. Depressive symptoms increased the odds of cognitive impairment in both strata, with a larger effect size in rural settings (OR = 2.23, 95% CI [1.41, 3.54]). Conversely, the association between depressive symptoms and dementia was only significant in urban settings (OR = 3.20, 95% CI [1.99, 5.15]). Conclusions: Falls and depressive symptoms were significantly associated with the odds of cognitive impairment and dementia, with significant differential effects between rural and urban older adults.