People Living With Dementia in Rural Areas are Most Likely to Report Unmet Service Needs in Home- and Community-Based Services in the United States

Abstract

Purpose

Most older adults prefer aging in place, for which home- and community-based services (HCBS) play an essential role. However, it is unknown whether rural-urban differences in unmet HCBS needs differ by dementia status, which is an important evidence gap to develop targeted interventions to improve HCBS access. Therefore, we evaluated associations of rural-urban continuum (RUCA classification) with consumer-reported unmet HCBS needs by dementia status.

Methods

We analyzed data from the National Core Indicators- Aging & Disability survey (2016-2019; 14,645 community-dwelling consumers; age, ≥65years; 23 states) using logistic regression, comparing adjusted odds ratios (OR) of consumer-reported unmet HCBS needs across rural-urban continuum, stratified by dementia.

Findings

Among people living with dementia (PLWD, n = 2438), compared to metropolitan areas, prevalence of unmet HCBS needs was greater in micropolitan areas (35.4% versus 30.7% consumers; OR, 1.32, 95% CI, 0.98–1.77), small towns (36.3% consumers; OR, 1.44, 95% CI, 0.97–2.13), and rural areas (44.8% consumers; OR, 1.83, 95% CI, 1.11–3.04). These associations were reversed in those without dementia (n = 12,207). Compared with metropolitan areas, prevalence of unmet HCBS needs was lower among those in micropolitan areas (28.7% vs 31.4% consumers; OR, 0.82; 95% CI 0.72–0.93), small towns (29.3%; OR 0.85; 95% CI 0.73–1.00) and rural areas (25.4%; OR, 0.73, 95% CI, 0.58-0.90).

Conclusion

Among PLWD, unmet HCBS needs are significantly greater in rural areas. These findings highlight the critical need for dementia-capable HCBS in rural areas to improve equitable access to these essential services among PLWD.