# Rural-Urban Differences in Cognitive Impairment and Medication Prescribing Pre- Dementia Diagnosis

## TL;DR

Rural veterans are less likely to receive specific cognitive impairment diagnoses and dementia medications before a dementia diagnosis compared to urban veterans.

## Contribution

The study reveals rural-urban disparities in cognitive impairment documentation and medication use before dementia diagnosis in the U.S. VA system.

## Key findings

- Urban veterans had higher documentation of mild cognitive impairment pre-dementia diagnosis.
- Rural veterans were more likely to receive dementia medications without prior MCI documentation.
- Disparities in diagnosis and treatment were observed, potentially due to access to specialists.

## Abstract

Documentation of a dementia diagnosis provides access to a pathway of evidence-based treatment. However, delayed diagnosis is common, particularly in rural areas with limited access to dementia specialists, often resulting in documentation of less specific cognitive impairment and prescribing of dementia medications pre-dementia diagnosis. We described patterns of rural-urban differences in cognitive impairment and dementia medication prescribing pre-dementia diagnosis in the Veterans Affairs (VA), the largest integrated healthcare system in the U.S. We identified veterans ≥at least 50 years old with two ICD-10-CM dementia diagnoses, with first diagnosis in 2022 or 2023. Documentation of diagnoses of mild cognitive impairment (MCI), amnesia/memory loss, and receipt of dementia medications were compared among rural and urban veterans in the two years preceding the first dementia diagnosis. In 2022-23, 89,482 veterans had a first dementia diagnosis (mean age: 79 years, 97% men). Of these 89,482 veterans, 67% resided in urban vs. 33% in rural areas, with 43% living in the South. More urban vs. rural veterans had documentation of MCI (20% vs. 17.5%) pre-dementia diagnosis. As expected, more rural Veterans had documentation of an amnesia/memory loss (15% vs. 13%), received a dementia medication (12% vs. 10%), and received a dementia medication without documentation of MCI or amnesia/memory loss pre-dementia diagnosis (5.1% vs. 4.2%) (p < 0.01 for all comparisons above). Particularly for rural veterans, dementia-targeting treatment often began well before dementia diagnosis. Whether these patterns reflect delays in formally classifying cognitive impairment as dementia, gaps in access to specialists or other factors should be further explored.