Understanding the drivers of migration among patients from Puerto Rico with Alzheimer’s and related dementias

Brown researcher receives NIA grant to study migration patterns and health care.

In recent years, many Puerto Rican residents have been displaced due to hurricanes, other natural disasters, and the ensuing economic struggles, opting to move to the United States mainland. This is particularly true for older adults who are dealing with chronic illness and have limited access to health care services, low-income subsidies, and good living conditions. For people with Alzheimer’s disease and related dementias (ADRD), the situation is even more challenging because their long-term care is not covered by the Medicaid program in Puerto Rico.

Maricruz Rivera-Hernandez, assistant professor of health services, policy and practice at the Brown University School of Public Health, has received a nearly $2 million grant from the National Institute on Aging (NIA) to study migration rates, identify causes, and examine the effect of migration on health outcomes for Puerto Rican Medicare beneficiaries with ADRD.

Rivera-Hernandez and her team have several working hypotheses about how ADRD affects migration from Puerto Rico. They suggest that older adults with an ADRD diagnosis might be more likely to move away from their homes compared to those without a diagnosis. They also posit that Hurricane Maria, which devastated the island in 2017, increased migration rates for people with pre-existing ADRD. The team additionally believes that people with ADRD who moved away from Puerto Rico may need more health care, and could end up spending more on care than those who stayed on the island.

The findings from this study can guide efforts to support older adults in Puerto Rico to age in their homes, improve services for new migrants with ADRD and other chronic conditions, and address existing gaps in services. The results could also inform changes in funding and benefits for Medicare/Medicaid programs and help increase access to specialized care in Puerto Rico.

We spoke with Professor Rivera-Hernandez about her work.

Thanks for joining us! Please tell us about your project.

Our research focuses on understanding why older adults from Puerto Rico, especially those with Alzheimer’s disease or related dementias (ADRD), are leaving the island at a high rate. We believe that factors such as the high poverty rate, higher unemployment rate, prevalence of chronic conditions, and lack of access to long-term services and support in Puerto Rico are pushing these individuals to migrate to the mainland U.S.

Our study aims to examine the relationship between migration and ADRD on mortality, morbidity and hospitalizations among Puerto Rican Medicare beneficiaries. We want to understand whether these older adults are leaving Puerto Rico to access long-term care services and support that they may not have access to in Puerto Rico.

By examining the drivers of migration among older adults from Puerto Rico, we hope to identify effective interventions to help them continue aging at home in Puerto Rico and improve access to long-term services and support.

What interventions have the potential to help older adults in Puerto Rico age at home?

There are several. First, our findings could be used to improve the structure of Medicare and Medicaid funding in Puerto Rico, where access to long-term services and support is currently limited. Policymakers could consider restructuring how these programs are funded to provide more services and support to those in need. 

Additionally, since specialty care is also lacking in Puerto Rico and many physicians are leaving the island, incentives could be put in place to encourage health care professionals to stay and provide much-needed care to the elderly population. These measures would improve access to specialized care, which is often necessary for older adults with complex needs and conditions such as dementia. 

I hope my research will identify other gaps in the health care system and inform efforts to improve conditions for older adults living in Puerto Rico.

Can you give us some insight into how climate change is affecting the health care workforce in Puerto Rico?

Yes, the increasing frequency and intensity of hurricanes and other natural disasters pose a significant threat to health care infrastructure and human resources in Puerto Rico. It exacerbates the issue of physician shortage, especially in rural areas, where the health care system is already struggling to meet the needs of the population.

We need to prioritize the resilience and adaptation of health care systems in the face of climate change, and ensure that providers have the resources and support they need to continue working during and after disasters. It’s also important to track the long-term health outcomes of people who have experienced the impacts of natural disasters and displacement.

Please explain the “Hispanic paradox,” and how it factors into your work.

Our collaborator at the University of Texas Medical Branch, Kyriakos Markides, has studied migration patterns among Mexican Americans and the so-called “Hispanic paradox.” The term refers to the observation that Hispanic adults in the U.S. have better health outcomes than other populations, despite facing social and economic disadvantages. One explanation for this paradox is that healthier individuals are more likely to migrate because they have the resources and ability to make the journey.

However we are seeing a different pattern in Puerto Rico, where individuals with complex health conditions are migrating. This could be due to a variety of factors, such as differences in insurance or familial ties. Markides’ expertise in migration patterns and outcomes among Hispanic populations provides important context and insights for our research on Puerto Rican migration.

At Brown our team includes researchers from the Department of Health Services, Policy and Practice and the Department of Biostatistics, including David Meyers, Daeho KimAmal Trivedi and Christopher Schmid, who are experts in statistical analysis, data management of complex clinical and administrative databases, health system changes and federal health policies. Additionally, we are joined by collaborators from Puerto Rico on our research team. 

Together we are working to better understand the implications of Puerto Rican migration for health care providers and policymakers, and to identify potential solutions to the challenges faced by this population.