Associations of Greenness, Parks, and Blue Space With Neurodegenerative Disease Hospitalizations Among Older US Adults

Key Points

Question

Are measures of the natural environment associated with hospitalization for Alzheimer disease and related dementias (ADRD) and Parkinson disease (PD) among older individuals?

Findings

In this US-based cohort study of approximately 62 million Medicare beneficiaries aged 65 years or older, protective associations of greenness (normalized difference vegetation index), park cover, and blue space cover with PD hospitalization were observed. Greenness, but not park or blue space cover, was associated with a decreased risk of ADRD hospitalization.

Meaning

These findings suggest that exposure to some natural environments may reduce the risk of ADRD and PD hospitalization among older adults.

Abstract

This cohort study explores the association of natural environments—using measures of greenness, parks, and blue space—with hospitalizations for Alzheimer disease and related dementias and Parkinson disease among older individuals in the US.

Abstract

Importance

Exposure to natural environments has been associated with health outcomes related to neurological diseases. However, the few studies that have examined associations of natural environments with neurological diseases report mixed findings.

Objective

To evaluate associations of natural environments with hospital admissions for Alzheimer disease and related dementias (ADRD) and Parkinson disease (PD) among older adults in the US.

Design, Setting, and Participants

This open cohort study included fee-for-service Medicare beneficiaries aged 65 years or older who lived in the contiguous US from January 1, 2000, to December 31, 2016. Beneficiaries entered the cohort on January 1, 2000, or January 1 of the year after enrollment. Data from US Medicare enrollment and Medicare Provider Analysis and Review files, which contain information about individual-level covariates and all hospital admissions for Medicare fee-for-service beneficiaries, were analyzed between January 2021 and September 2022.

Exposures

Differences in IQRs for zip code–level greenness (normalized difference vegetation index [NDVI]), percentage park cover, and percentage blue space cover (surface water; ≥1.0% vs <1.0%).

Main Outcomes and Measures

The main outcome was first hospitalizations with a primary or secondary discharge diagnosis of ADRD or PD. To examine associations of exposures to natural environments with ADRD and PD hospitalization, we used Cox-equivalent Poisson models.

Results

We included 61 662 472 and 61 673 367 Medicare beneficiaries in the ADRD and PD cohorts, respectively. For both cohorts, 55.2% of beneficiaries were women. Most beneficiaries in both cohorts were White (84.4%), were not eligible for Medicaid (87.6%), and were aged 65 to 74 years (76.6%) at study entry. We observed 7 737 609 and 1 168 940 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders (eg, Medicaid eligibility and zip code–level median household income), NDVI was negatively associated with ADRD hospitalization (hazard ratio [HR], 0.95 [95% CI, 0.94-0.96], per IQR increase). We found no evidence of an association of percentage park and blue space cover with ADRD hospitalization. In contrast, NDVI (HR, 0.94 [95% CI, 0.93-0.95], per IQR increase), percentage park cover (HR, 0.97 [95% CI, 0.97-0.98], per IQR increase), and blue space cover (HR, 0.97 [95% CI, 0.96-0.98], ≥1.0% vs <1.0%) were associated with a decrease in PD hospitalizations. Patterns of effect modification by demographics differed between exposures.

Conclusions and Relevance

The findings of this cohort study suggest that some natural environments are associated with a decreased risk of ADRD and PD hospitalization.