Aging Research Summer 2015

Alzheimer’s in North Carolina: At the County Level

Students in the Master of Public Policy program at Duke’s Sanford School of Public Policy spent part of their spring semester examining a policy issue for the N.C. Center for Public Policy Research.

The students investigated Alzheimer’s disease in North Carolina, looking at the rates of the disease, caregiving options for patients, and also looked to other states to learn about different options for comprehensive plans.

The students’ report, which includes recommendations for action in our state, is presented in this series of blog posts. Today’s post takes a specific look at Alzheimer’s mortality rates in some North Carolina counties, and analyzes possible reasons for the range in impact. Read previous posts here:

Part One in the series provides an introduction to Alzheimer’s disease and an overview of prevalence rates

Part Two discusses caregiving options

Part Three takes a look at programs and services supporting Alzheimer’s patients in N.C.

Part Four outlines how coverage for Alzheimer’s care continues to change, and touches on mental health reform in the state

Note: The pictures used in this series are from the Alzheimer’s North Carolina organization, a nonprofit  dedicated to education, support, and advocacy for Alzheimer’s patients and their families. Visit their website here:

Pictures also featured from The A.R.C. Community, long-term care facilities in North Carolina for residents with Alzheimer’s.

Alzheimer’s in North Carolina at the County Level


          Between 2001 and 2013, North Carolina had an average Alzheimer’s mortality rate of 28.4 deaths per 100,000 people. During the same period, 46 of 100 counties recorded particularly high Alzheimer’s mortality rates, in excess of 40 deaths per 100,000. Many of these counties only recorded a single year with an especially high rate. However, a handful demonstrated consistently high mortality rates throughout this period. In particular, neighboring counties Union and Mecklenburg reported consistently high rates of Alzheimer’s mortality over the 13-year period. The average Alzheimer’s mortality rate in Union County over this period was 54.7 deaths per 100,000 and Mecklenburg County’s was 43.97. In four of these years, Union County had the highest rate in North Carolina.


Highest County Alzheimer’s Mortality Rates, 2001-2013

Age-adjusted, per 100,000 population (click to enlarge)


          Union, Mecklenburg, and Iredell are contiguous counties in the Southern Piedmont. Granville is the only county in the state with a chronically high Alzheimer’s mortality rate not adjacent to other counties with similarly high rates.


North Carolina Alzheimer’s disease Mortality Rates by County, 2001-2013


          The reason for chronically high Alzheimer’s mortality rates in certain regions within North Carolina is unclear. Mortality rate data for Alzheimer’s are typically gathered from death certificates that identify Alzheimer’s as the primary cause of death. For a consistent number of people to die annually of the same disease in a particular location suggests that some regional characteristic may play a role in prevalence. Because the data have been age-adjusted, particularly high mortality rates do not reflect the presence of a disproportionately large elderly population.

Union County has the highest Alzheimer’s mortality rate in the state.

          There are two mechanisms that could contribute to a disproportionate impact for some counties:
                    1) A county may feature particular amenities that attract people with Alzheimer’s.
                    2) A county may have a population that is especially prone to developing Alzheimer’s.

          In the former case, county variations in Alzheimer’s care capacity may be at play. In the latter, certain environmental or regional characteristics may be to blame. Alzheimer’s care facilities in North Carolina are not necessarily located in areas with the greatest need. Care capacity for Alzheimer’s is concentrated in urban counties in the middle of the state. Mecklenburg is the only county most afflicted by Alzheimer’s with a large number of facility beds dedicated to Alzheimer’s patients. Most counties with high Alzheimer’s mortality rates are in the southern Piedmont or the Western region. Between 2001 and 2013, New Hanover County in Southeastern North Carolina consistently had the lowest Alzheimer’s mortality rate in the state, with an average of 11.5 deaths per 100,000. Despite its low mortality rate, New Hanover exceeds 95% of North Carolina counties in Alzheimer’s care capacity.


Alzheimer’s Care Facilities by County

alzheimers5Despite its low Alzheimer’s mortality rate, New Hanover exceeds 95% of North Carolina counties in Alzheimer’s care capacity.

          In 2008, Union County commissioned a study by geologists at Duke University on arsenic levels in the groundwater. The study ended due to a lack of funding. Yet the Union County Health Department was “interested in pursuing any potential linkage between the arsenic in well water with high Alzheimer’s rates, or cancer incidence (Morgan, 2012, 13).” Many residents of Union County rely heavily on well water, mostly from private wells not  subject to filtration requirements. “The county has not extended water lines across the entire county, leaving some residents reliant on well water which is a concern. Filtration systems are available, but are financially out of reach for many families (Morgan, 2012, 13).” The map below shows especially high concentrations of arsenic in North Carolina’s Slate Belt, which lies directly beneath many counties in the southern Piedmont, including Union and Mecklenburg.


Distribution of Arsenic in Groundwater in North Carolina


          Besides care facilities and groundwater contamination, other possibilities might explain the county-level variation in Alzheimer’s rates. Other characteristics that might play a role include idiosyncrasies in how cause of death is reported, exposure to other toxins, or other unknown variations in regional or environmental factors. Because the causes of Alzheimer’s disease remain largely unknown, no method exists to determine with certainty what factors cause such variation within North Carolina. 1


Note: Here is information about this student project, provided by the Duke Sanford School of Public Policy.

This student presentation was prepared during the spring of 2015 in partial completion of the requirements for PUBPOL 804, a course in the Master of Public Policy Program at the Sanford School of Public Policy at Duke University. The research, analysis, policy alternatives, and recommendations contained in this report are the work of the student team that authored the report, and do not represent the official or unofficial views of the Sanford School of Public Policy or of Duke University. Without the specific permission of its authors, this report may not be used or cited for any purpose other than to inform the client organization about the subject matter. The authors relied in many instances on data provided to them by the client and related organizations and make no independent representations as to the accuracy of the data.

Show 1 footnote

  1. Works Cited for Full Project

    ACT on Alzheimer’s. (2014). Retrieved February 17, 2015, from ACT on Alzheimer’s:

    Alzheimer Europe. (2013). P8. Dementia-friendly communities. Retrieved February 19, 2015, from
    Alzheimer Europe: 2013-St-Julian-s/Detailed-programme-abstracts-and-presentations/P8.-Dementia-friendly-communities

    Alzheimer’s Association “State Alzheimer’s Disease Plans.” (2015, February 1). Retrieved February
    20, 2015, from

    Alzheimer’s Association. (2011). The National Alzheimer’s Project Act.” Alzheimer’s Association,
    2014. Retrieved April 9, 2015, from

    Alzheimer’s Association. (2014). “National Plan to Address Alzheimer’s Disease,” Alzheimer’s
    Association, 2014. Retrieved April 9, 2015, from

    Alzheimer’s Association. (2015) 2015 Alzheimer’s disease Facts and Figures. Alzheimer’s
    Association. Retrieved April 9, 2015, from

    Assistant Secretary for Planning and Evaluation. (2014). National Alzheimer’s Project Act. U.S.
    Department of Health and Human Services, 2014. Retrieved April 9, 2015, from

    Bratts-Brown, W. (2013, December 27). Memorandum: CAP/DA Slot Utilization and Waitlist Management. Retrieved April 8, 2015, from

    Bynum, J. (2014). The Long Reach of Alzheimer’s disease: Patients, Practice, And Policy. Health Affairs, 33(4), 534-540. Retrieved February 2, 2015, from

    Carter, Christine L., Resnick, Eileen M, Mallampalli, Monica, Kalbarczyk, Anna. (2012) Sex and Gender Differences in Alzheimer’s disease: Recommendations for Future Research. Journal of Women’s Health 21(10): 1018-1023.

    Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2013 on CDC WONDER Online Database, released October 2014. Data are from the Compressed Mortality File 1999-2013 Series 20 No. 2S, 2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Apr 5, 2015 2:14:16 PM

    Centers for Disease Control and Prevention. Healthy Aging: Alzheimer’s Disease. Retrieved April 17, 2015 from

    Chin, Alexander L., Selamawit Negash, and Roy Hamilton. (2011) Diversity And Disparity In Dementia. Alzheimer Disease & Associated Disorders 25(3): 187-195.

    Facilities with Special Care Units. (2015, March 16). Retrieved March 20, 2015, from

    Foldes, S. and Long, K (2014, May).The Minnesota Economic Model of Dementia: Demonstrating Healthcare Cost Savings with the New York University Caregiver Support Intervention. Retrieved April 11, 2015, from mentia%20White%20Paper%20Final.pdf

    Fox, C., Maidment, I., Mooniz-Cook, E., White, J., Thyrian, J. R., Young, J., et al. (2013). Optimising primary care for people with dementia. Mental Health in Family Medicine. 10 (3), 143–151.

    Gaugler, J. E., Yu, F., Davila, H. W., & Shippee, T. (2014). Alzheimer’s disease And Nursing Homes. Health Affairs, 33(4), 650-657.

    Georgia Department of Human Services “Georgia Alzheimer’s Disease and Related Dementias State Plan.” (2014, June 23). Retrieved February 19, 2015, from

    Grant launches collaborative effort to combat Alzheimer’s (2015). Retrieved April 11, 2015, from

    Group Homes/Special Care Units. (2013, March 6). Retrieved February 17, 2015, from

    Gurland, Barry J.; Wilder, David E.; Lantigua, Rafael; Sterm, Yakov; Chen, Jiming; Killeffer, Eloise H.P., Mayeux, Richard. (1999). Rates of dementia in three ethnracial groups. International Journal of Geriatric Psychiatry, 14, 481-493.

    Hampel, H., Frölich, L., Hoffman, W., Prvulovic, D., Riepe, M. W., Stefan, T., et al. (2011). The future of Alzheimer’s disease: The next 10 years. Progress in Neurobiology, 95, 718–728.

    Hebert, L. E. (2001). Is The Risk Of Developing Alzheimer’s disease Greater For Women Than For Men? American Journal of Epidemiology 153 (2), 132-136.

    Hebert, Liesi E.; Weuve, Jennifer; Scherr; Paul A., et al. (2013, February 6). Alzheimer disease in the United States (2010−2050) estimated using the 2010 census. Neurology published online. DOI: DOI 10.1212/WNL.0b013e31828726f5

    a. Hoban, R. (2012, November 4). Rate Cuts Threaten Dementia Care Facilities. Retrieved February 17, 2015, from care-facilities

    b.Hoban, R. (2012, December 14). Alzheimer’s Patients Caught Up in State Medicaid Service Changes. Retrieved February 17, 2015, from service-changes/

    Hoban R. (2013, February 4). No Fix in Sight Yet for Alzheimer’s Special Care Units. Retrieved April 28, 2015, from for-alzheimers-special-care-units/

    Hoban, R. (2013, June 11). House & Senate Budgets Compared. Retrieved April 7, 2015, from, R., Singh, J., &

    Namkoong, H. (2014, August 1). Hospitals, Adult Care Homes Big Losers in Budget. Retrieved February 17, 2015, from budget/

    Hoban, R., Singh, J., & Namkoong, H. (2015). FINAL: The Health and Human Services Budgets Compared. Retrieved February 17, 2015, from and-human-services-budgets compared/

    In the Public Interest. “North Carolina Mental Health System.” (2015). Retrieved April 29, 2015,

    Kelly, C., & Williams, I. (2007). Providing Dementia-Specific Services to Family Caregivers: North Carolina’s Project C.A.R.E. Program. Journal of Applied Gerontology, 26(4), 399-412. Retrieved February 18, 2015, from Specific_Services.pdf

    Land of Sky Regional Council: Project C.A.R.E. (2012). Retrieved April 8, 2015, from

    Leslie, L., & Morgan, D. (2012, December 13). Medicaid benefit cuts impact thousands of Alzheimer’s patients. Retrieved February 17, 2015, from cuts-impact-thousands-of-alzheimer-s-patients/11874686/

    Lin, P. J., Fillit, H. M., Cohen, J. T., & Neumann, P. J. (2013). Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer’s disease and related disorders. Alzheimer’s & Dementia, 9(1), 30-38.

    Long, K. H., Moriarty, J. P., Mittelman, M. S., & Foldes, S. S. (2014). Estimating The Potential Cost Savings From The New York University Caregiver Intervention In Minnesota. Health Affairs, 33 (4), 596-604.

    Mastry, Olivia. (2015, March). Speech to the North Carolina Taskforce on Alzheimer’s disease and
    Related Dementia.

    Miller, Debra. (2011, September). Alzheimer’s disease and Caregiving. The Council of State
    Governments Knowledge Center. Retrieved April 11, 2015, from:

    Minnesota Board on Aging (2011). Preparing Minnesota for Alzheimer’s: the Budgetary, Social and Personal Impacts. Retrieved February 17, 2015, from:

    Morgan, J. (2008). Union County Community Health Assessment 2008. Retrieved April 1, 2015, from

    Morgan, J. (2012). Union County 2012 Community Health Assessment. Retrieved April 1, 2015, from

    National Alliance for Caregiving & Alzheimer’s Foundation of America. (2014). From plan to practice: Implementing the National Alzheimer’s Plan in Your State. National Alliance for Caregiving.NC PACE Association: History and Growth. (2015). Retrieved April 9, 2015, from

    NC PACE Association: PACE Sites. (2015). Retrieved April 9, 2015, from pace-sites
    North Carolina Community Alternatives Program for Disabled Adults Waiver (CAP/DA) (2014, March). Retrieved April 7, 2015, from nc-community-alternatives-program for-disabled-adults.html

    North Carolina Department of Health and Human Services. “Facilities with Special Care Unit Beds.” (2015, April 16). Retrieved April 29, 2015, from

    North Carolina Division of Aging and Adult Services: Home and Community Care Block Grant (2013, March 14). Retrieved April 9, 2015, from

    North Carolina Medicaid Special Bulletin: Cap Limits on PACE Enrollments for State Fiscal Year 2014 (2014, May). Retrieved April 10, 2015, from

    North Carolina Mental Health System. (2015). In the Public Interest. Retrieved April 10, 2015, from

    North Carolina’s Family Caregiver Support Program. (2014, December 11). Retrieved February 1, 2015, from

    Oakes, A. (2013, September 3). NC continues stopgap funding for group homes. Retrieved February 17, 2015, from homes/article_1b33c8c6-e796-5614-804f-2977c120412a.html

    Reauthorize the Older Americans Act. (2015, March 1). Retrieved April 8, 2015, from

    Reinhard, S., Feinberg, L., Choula, R. (2012). A Call to Action: What Experts Say Needs to be Done to Meet the Challenges of Family Caregiving. AARP Public Policy Institute. Retrieved April 11, 2015, from Reitz, C., Brayne, C., & Mayeux, R. (2011). Epidemiology of Alzheimer disease. Nature Reviews Neurology, 7, 137-152.

    Senate Bill 466 (2015). Retrieved April 11, 2015, from

    Shaw, L. (2013). Response to NC Department of Health and Human Services Division of Medical Assistance Request For Information RFI-DMA 100-13. Retrieved April 8, 2015, from

    Social Worker (BSW) Salaries. (2015). Retrieved April 11, 2015, from

    Sosa-Ortiz, A., Acosta-Castillo, I., & Prince, M. J. (2012). Epidemiology of Dementias and Alzheimer’s disease. Archives of Medical Research, 43, 600-608.

Leave a comment

  • Cary mcdonald

    Since 2011, verified incidence of Lyme infection (Borrelia via Tick bite) in North Carolina has more than doubled. Recent work has revealed Alzheimer’s is directed by Tau protein (not spread through the brain via Amyloids, or other channels) from a central location (which can vary), from nerve cell to active nerve cell, strongly suggesting a prion-like origin. Borrella is known to disengage it’s DNA plasmids, which can demonstrate a ‘Tau’ like behavior. The principle urban vector in N.Carolina of Lyme ticks are raccoons (Coast counties: 60% infected), not deer. As was reported in Houston Texas, patients need not demonstrate ‘Lyme’ symptoms to be infected ( ) I suggest that correlation of Alzheimer incidence simply with raccoon density (in their backyards 10 years ago) would perhaps be of value.

    • Jack

      Very good observation. I’ve noticed that many doctors use Alzheimer’s and dementia interchangeably. Some doctors document these as the cause of death 80-85% of the time. Maybe they deal mostly with this illness or over “prescribe” it.

Previous article

Alzheimer’s in North Carolina: Part Four

by Judson Bonick, Rose Kerber, Lauren Oliver, & Ariadne Rivera on July 20, 2015

Next article

Alzheimer’s in North Carolina: Task Force on Alzheimer’s

by Judson Bonick, Rose Kerber, Lauren Oliver, & Ariadne Rivera on July 24, 2015