Further from Help: Dementia in Rural and Remote Communities

In many countries, people living with dementia in rural and remote places see specialists less often and spend more of their time after diagnosis in care homes, and some of the highest dementia rates recorded anywhere are in remote Indigenous communities. The gap is not inevitable: Sweden's dementia registry found people diagnosed in rural areas received a more complete diagnostic work-up than those in cities^[1].

Distance changes what a dementia diagnosis involves. A memory assessment can mean a long round trip, often with no public transport, fewer specialists and thinner home care. None of this is about the people who live there: it is about where services have been built and how they reach out. The evidence below, drawn from Australia, Canada, China, India, Sweden, Scotland and the United States, shows where those gaps are widest and what has narrowed them.

In several large countries, dementia is more common in rural areas, but the counting varies

Around the world, 57 million people were living with dementia in 2021, and over 60% of them live in low- and middle-income countries, according to the World Health Organization^[4].

The two largest national studies we found point the same way. In India, the Longitudinal Aging Study in India estimated that 7.4% of adults aged 60 and over were living with dementia between 2017 and 2020, about 8.8 million people, with prevalence of 8.4% in rural areas against 5.3% in urban areas^[5]. The authors found that differences in sociodemographic characteristics drove most of the variation between states. In China, a national study of 46,011 adults aged 60 and over (2015 to 2018) estimated dementia prevalence at 6.0%, and found that rural residence was associated with 1.16 times the odds of dementia and 1.45 times the odds of mild cognitive impairment^[6]. A separate analysis of Chinese survey data for 2018 estimated provincial prevalence ranging from 2.62% to 13.53%^[7].

In wealthier countries the picture is less clear. A systematic review of 51 studies that compared places using identical methods found "some evidence" of an effect of rural living: odds ratios of 1.11 for prevalence and 1.20 for incidence, with 90% confidence intervals that included no difference. The association was stronger for Alzheimer's disease where early-life rural living was captured (prevalence odds ratio 2.22). The reviewers noted that few studies had been done in resource-poor countries^[8].

Australia shows why the method matters. Using the national Survey of Disability, Ageing and Carers, researchers found that in 2018 older adults in major cities had 1.12 times the odds of having dementia recorded in the survey compared with those in outer regional and remote areas, the opposite direction to India and China^[9]. Surveys, health records and door-to-door assessments each count people differently. For how dementia varies between regions within countries, see our study of regional variation.

Some of the highest dementia rates recorded are in remote Indigenous communities

The clearest rural and remote signal in the evidence comes from Indigenous communities. In the Kimberley region in the far north of Western Australia, researchers assessed 363 Aboriginal people aged over 45 with the Kimberley Indigenous Cognitive Assessment, a tool developed for the region, followed by specialist review. They found dementia in 12.4% and cognitive impairment short of dementia in a further 8.0%^[2].

When the same group was followed up about five years later, the incidence of dementia among people over 60 was 21.0 per 1,000 person-years. The authors concluded that dementia incidence in Aboriginal Australians is "among the highest in the world", and found it was associated with age and head injury. By follow-up, 109 of the original participants (30%) had died^[10].

In Canada, physician records in Alberta showed an age-standardised prevalence of diagnosed dementia among First Nations people of 7.5 per 1,000 in 2009, against 5.6 per 1,000 for other Albertans. The rate rose more quickly among First Nations people, and dementia disproportionately affected younger age groups and men^[11]. These are treated cases, so they depend on people reaching a doctor and receiving a diagnosis; they are not a count of everyone living with dementia.

These figures should be read alongside their causes. The Alberta researchers linked the rise to population aging, changing perceptions of dementia, higher rates of associated risk factors, the social determinants of health and other illnesses^[11]: circumstances, not anything inherent in the people affected. Rural and remote workers in Australia have said the same gap shows up in care: in a national survey of 558 health and aged care workers in rural and remote areas, a majority considered the dementia care in their own workplace inadequate overall, and specifically for First Nations clients and clients from culturally and linguistically diverse backgrounds^[12]. For wider differences between ethnic groups, see our study of ethnicity and dementia.

Rural diagnosis more often rests on primary care alone, though Sweden shows it need not fall short

In North America, studies of health records find rural people with dementia see some specialists less. Among 8,430 newly diagnosed people aged 40 to 64 with young-onset dementia in US commercial insurance claims (2012 to 2017), those in rural areas had 0.83 times the odds of receiving neuropsychological testing and 0.72 times the odds of seeing a psychologist, and 1.40 times the odds of having only primary care visits for diagnosis and symptom management. There were no significant differences in brain imaging or in visits to neurologists or psychiatrists^[13].

In Saskatchewan, Canada, a study of 2,024 people aged 65 and over diagnosed in 2013–14 (617 rural, 1,407 urban) found rural people with dementia had a lower likelihood of at least one specialist visit, and fewer specialist visits, in every year from five years before diagnosis to five years after. Hospital admission did not differ^[14]. A systematic review of 38 studies reached a similar overall picture: fewer physician visits of any kind for rural people with dementia^[15].

US researchers have described "dementia diagnostic deserts": places where rurality, primary care shortages and high social deprivation converge. There, nurse practitioners and physician assistants are often the frontline clinicians but "face significant training gaps"^[16].

Sweden is an important counterpoint. In the Swedish Dementia Registry (2007 to 2014; more than 58,000 patients), people diagnosed in rural areas were more likely than urban patients to receive a complete basic examination, cognitive testing, blood tests and brain imaging. In primary care, the complete basic work-up was done less often in urban and intermediate areas than in rural ones^[1]. Distance from a specialist need not mean a thinner assessment.

In Scotland's largest remote and rural region, interviews with 18 people (six living with dementia and 12 family members) in 2010 found experiences varied at every stage. The authors warned that without support after diagnosis, "Government targets for diagnosis are just that, quota targets"^[17]. National diagnosis rates are covered in our study of dementia diagnosis rates.

After diagnosis, rural families carry more of the care, and care homes fill the gaps

The largest study we found of what happens after diagnosis followed 555,333 US Medicare beneficiaries newly diagnosed with dementia in 2010, 55,771 of them (10.0%) in rural counties. After adjusting for individual differences, rural and small-town residents survived about 1.5 months less than those in metropolitan counties. Rural residents spent a share of their days in nursing homes 5.7 percentage points higher, and a share of days living in the community without home health care 4.6 percentage points lower. Rural beneficiaries were also more likely to be eligible for Medicaid, the US means-tested health programme (25.6% against 16.9%)^[18]. The systematic review of 38 studies found the same broad pattern across countries: lower use of home care services and higher use of nursing homes for rural people with dementia, and higher mortality^[15].

Sweden again differs. In the Swedish Dementia Registry, urban patients were more likely than rural ones to be living in a nursing home when diagnosed (odds ratio 1.49), and there was no difference in survival after diagnosis between rural and urban areas^[19]. In Sweden, at least, rural and urban outcomes after diagnosis looked much the same.

US death statistics differ by county type too, though not in a simple rural gradient. In 2014, the age-adjusted death rate from Alzheimer's disease was lowest in large central (23.7 per 100,000) and large fringe (22.6) metropolitan counties, highest in medium (28.0) and small (27.9) metropolitan counties, and 27.7 in micropolitan and 27.1 in the most rural (noncore) counties^[20]. These are deaths with Alzheimer's disease recorded as the underlying cause, so they also reflect how death certificates are completed in different places. More people with Alzheimer's disease were also dying at home, which the authors read as a sign of growing demands on carers. For care homes across settings, see our study of dementia and care homes.

Rural carers report more days of poor physical health

A US analysis of the Behavioral Risk Factor Surveillance System (2020 to 2022) compared 2,311 rural and 15,094 urban carers of people with dementia. About 25.7% of rural carers and 20.8% of urban carers reported 14 or more days of poor mental health in the past month; 25% of rural and 10% of urban carers reported 14 or more days of poor physical health. After adjusting for other differences, rural carers had significantly higher odds of frequent poor physical health, while frequent poor mental health was at similar levels^[21].

For the wider evidence, see our study of carers' health.

Telehealth cuts long journeys, but the evidence on outcomes is still thin

Video appointments are the most studied answer to distance. Saskatchewan's Rural and Remote Memory Clinic in Canada uses telehealth before and after an in-person clinic day. In an evaluation with 169 patients, telehealth appointments cut travel by an average of 426 km per round trip. Coordinators rated 85% of patients and 92% of carers comfortable or very comfortable during telehealth, satisfaction was similar to in-person appointments and telehealth was rated significantly more convenient. People who lived further from a telehealth site were more likely to stop attending follow-up^[3].

Wider reviews are more cautious. A systematic review of 12 studies (two in Australia, five in Canada, one in Korea and four in the United States) found mixed results on whether cognitive tests work as reliably by video, and called the evidence on improved dementia management "inconclusive"^[22]. A 2026 scoping review of nine studies from the United States, Australia, Canada, Greece and the United Kingdom found the main barriers were limited connectivity, digital literacy, health impairments and carers' capacity; trust and continuity with clinicians helped; and training, dedicated coordinators and co-design with carers and people with dementia were the strategies that made it work^[23].

What the evidence asks of us

The World Health Organization's Global action plan on the public health response to dementia, endorsed in 2017 and extended to 2031, covers diagnosis, treatment and care^[4]. Some national strategies name rural and remote people directly: Canada's 2019 dementia strategy lists rural and remote communities among the groups needing emphasis, and states that "Indigenous communities and individuals have distinct dementia experiences and distinct needs"^[24]. The evidence above suggests what that should mean in practice.

• Equip primary care to diagnose well. Sweden's registry shows rural primary care can deliver a complete diagnostic work-up^[1]. Where rural diagnosis rests on primary care alone^[13], training, time and access to testing for the clinicians on the front line, including nurse practitioners, are the investments researchers call for^[16].
• Count rural and remote people properly. Prevalence estimates point in different directions depending on the method^[8][9]. Health planners need figures that report rurality, remoteness and Indigenous status using assessments that work in those communities, like the Kimberley tool^[2].
• Let Indigenous communities lead. With dementia incidence among the highest recorded^[10], services and research for First Nations, Aboriginal and Torres Strait Islander, Inuit and Métis people should be shaped by those communities, as Canada's strategy commits^[24], and supported by workforce training that local workers say is lacking^[12].
• Build support after diagnosis, not just diagnosis targets. Rural families in Scotland warned against diagnosis as a quota^[17]. Lower home care use and higher nursing home use in rural areas^[15][18] point to the need for home and community services that reach out of town.
• Fund telehealth as part of a service, not instead of one. Video appointments save long journeys^[3], but depend on connectivity, coordinators and carers' capacity^[23]. Evaluations should measure outcomes for people with dementia, which reviews found still uncertain^[22].
• Look after rural carers' health. Rural carers report more days of poor physical health^[21]; respite and carer support need to be within reach of where they live.

Post-diagnostic support is covered in more depth in our study of support after diagnosis, and the full library is at Dementia & Health research.

Language: this piece uses person-first language ("people living with dementia", "people with dementia"), as most dementia organisations and people with lived experience prefer, and uses clinical terms such as "Alzheimer's disease" or "mild cognitive impairment" only where a study, dataset or diagnosis refers to that specific condition.

Why we're publishing this

Distance shapes every step of dementia care. We have brought together the published evidence from several countries so that rural and remote services, Indigenous health organisations and carers' groups can make that case with figures. It shows where services have not yet reached people, and, through Sweden and Saskatchewan, that the gap can be narrowed.

How to read this data

The studies here use different sources: national surveys with cognitive assessment (India, China), a disability household survey (Australia), insurance and health records (the United States and Canada), a national dementia registry (Sweden), death certificates (the United States) and small interview studies (Scotland). Each defines "rural" differently, from census categories to county types, so the figures are not directly comparable across countries and should not be read as a trend. Health-record studies count diagnosed dementia only, and so can understate dementia where diagnosis is harder to reach. Odds ratios are reported as "times the odds", not as risk. Some figures are a decade or more old (Alberta 2009, US deaths 2014). Most studies we found were from high-income countries, and the evidence from rural areas of low- and middle-income countries is thinner, as the 2012 review also found^[8]. We read most papers as abstracts; where so, only figures stated in the abstract are used.

Use this data

Free to cite with attribution to Understanding Aging. Charities, carers' groups, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research and statistics for general information. It is not medical, care or financial advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's memory or health, please speak to a GP or another qualified health professional.

Sources

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