The rising burden of Alzheimer's disease mortality in rural America.

Since the 1990s, there has been a striking urban-rural divergence in life expectancy within the United States, with metropolitan areas achieving strong life expectancy increases and nonmetropolitan areas experiencing stagnation or actual declines in life expectancy. While Alzheimer's disease and related dementias (ADRD) are likely to pose a particular challenge in nonmetropolitan areas, we know relatively little about the level of ADRD mortality in nonmetropolitan areas, how it has changed over time, and whether it is contributing to metropolitan/nonmetropolitan life expectancy gaps. This study finds that ADRD mortality has risen more rapidly in nonmetropolitan areas than in all other metro areas (large central metros, suburbs, and medium/small cities) between 1999 and 2019. While death rates from ADRD were nearly identical in large central metros and nonmetros in 1999, a clear metro/nonmetro gradient has emerged and widened substantially over the past two decades. Today, nonmetros now experience the highest levels of ADRD mortality, while large central metros have the lowest levels. These metro/nonmetro gaps in ADRD differ substantially by region, with the largest gaps observed in the Middle Atlantic and South Atlantic. The contribution of ADRD to metro/nonmetro differences life expectancy at age 65 is now considerable in many regions, reaching up to 30% for women and 13% for men. In several regions, ADRD's contribution to female life expectancy gaps is on par with or exceeds the contributions of other leading causes of death such as heart disease, cancer, and chronic lower respiratory diseases. The rising burden of Alzheimer's disease mortality is likely to pose a substantial challenge in rural areas of the United States which are aging rapidly, experiencing adverse mortality trends, and increasingly disadvantaged in terms of socioeconomic resources and health care infrastructure.