Diverging cognitive benefits from education between rural and urban middle-aged and older adults in the USA

Background Subjective cognitive decline (SCD) is defined as self-reported increase in confusion or memory loss. There is limited research on the interplay between rural-urban residence and education on SCD. Aims Examine rural-urban differences in SCD, and whether education moderates this relationship. Method Respondents aged >= 45 years were queried about SCD in the 2022 Behavioral Risk Factor Surveillance System data, creating a sample size of 63 890. A logistic regression analysed the association between rural-urban residence and SCD, and moderation was tested by an interaction with education. Results SCD was more common among rural (12.0%) compared with urban (10.7%) residents. Rural residence was associated with 9% significantly higher odds of SCD compared with urban residence after adjusting for sociodemographic and health covariates (adjusted odds ratio (aOR) = 1.09, P = 0.01). There was a negative relationship between education level and SCD, including the association of college degree with 15% lower odds of SCD compared with less than high school degree (aOR = 0.85, P < 0.01). Education was a significant moderator, with higher education associated with lower odds of SCD for urban, but not rural, residents. Conclusions Rural setting and lower education were associated with higher odds of SCD, but higher education was protective for only urban residents. These results indicate that higher education may be a gateway for more opportunities and resources in urban settings, with cascading impacts on cognition. Future research should examine reasons for the diverging cognitive benefits from education depending on rural-urban residence.