Dementia Risk and Disadvantaged Neighborhoods

Importance: Residence in a disadvantaged neighborhood may be associated with an increased risk for cognitive impairment and dementia but is understudied in nationally representative populations. Objective: To investigate the association between the Area Deprivation Index (ADI) and dementia. Design, Setting, and Participants: Retrospective cohort study within the US Veterans Health Administration from October 1, 1999, to September 30, 2021, with a national cohort of older veterans receiving care in the largest integrated health care system in the United States. For each fiscal year, a 5% random sample was selected from all patients (n = 2 398 659). Patients with missing ADI information (n = 492 721) or missing sex information (n = 6) and prevalent dementia cases (n = 25 379) were excluded. Participants had to have at least 1 follow-up visit (n = 1 662 863). The final analytic sample was 1 637 484. Exposure: Neighborhoods were characterized with the ADI, which combines several sociodemographic indicators (eg, income, education, employment, and housing) into a census block group-level index of disadvantage. Participants were categorized into ADI rank quintiles by their census block group of residence (higher ADI rank quintile corresponds with more deprivation). Main Outcome and Measures: Time to dementia diagnosis (using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes) was estimated with Cox proportional hazards models with age as the time scale, and the sensitivity of the findings was evaluated with Fine-Gray proportional hazards models, accounting for competing risk of death. Results: Among the 1 637 484 Veterans Health Administration patients, the mean (SD) age was 68.6 (7.7) years, and 1 604 677 (98.0%) were men. A total of 7318 patients were Asian (0.4%), 151 818 (9.3%) were Black, 10 591 were Hispanic (0.6%), 1 422 713 (86.9%) were White, and 45 044 (2.8%) were of other or unknown race and ethnicity. During a mean (SD) follow-up of 11.0 (4.8) years, 12.8% of veterans developed dementia. Compared with veterans in the least disadvantaged neighborhood quintile, those in greater disadvantage groups had an increased risk of dementia in models adjusted for sex, race and ethnicity, and psychiatric and medical comorbid conditions (first quintile = reference; second quintile adjusted hazard ratio HR, 1.09 95% CI, 1.07-1.10; third quintile adjusted HR, 1.14 95% CI, 1.12-1.15; fourth quintile adjusted HR, 1.16 95% CI, 1.14-1.18; and fifth quintile adjusted HR, 1.22 95% CI, 1.21-1.24). Repeating the main analysis using competing risk for mortality led to similar results. Conclusions and Relevance: Results of this study suggest that residence within more disadvantaged neighborhoods was associated with higher risk of dementia among older veterans integrated in a national health care system.