The gender pain gap in prehospital analgesia: the role of patient and provider gender - an analysis of 106,888 helicopter emergency medical service (HEMS) missions.

Understanding why older adults move raises questions about preferences for aging in their homes and familiar surroundings (i.e., aging in place) (; ). Older adults often face increased aging-related physical and social needs, such as declining health and lack of institutional or family support, that may induce them to relocate to meet their needs elsewhere (; ). Although links between aging, health status, and later-life migration have been well explored and migration may in some cases be beneficial to later-life health (; ), less is known about how chronic diseases requiring intensive care, such as dementia, shape migration (). In 2018, Alzheimer’s Disease and Related Dementia (ADRD) prevalence among all Fee-for-Service (FFS) Medicare beneficiaries (including those under 65) was 14% in Puerto Rico (), and a report finds that one-third of Puerto Rican adults aged 45 and older who experience subjective cognitive decline live alone and manage multiple comorbidities (). Dementia prevalence rates among Puerto Rican beneficiaries surpass those of the mainland United States (U.S.) population overall (4%–6%), as well as for U.S. Hispanics (5%–11%), and Mexicans (≈10%) (; ; ; ; ). While poverty and limited economic opportunities rooted in institutional barriers and its colonial legacy remain key drivers of Puerto Rico’s increasing outmigration trend (; ; ; ), this research investigates whether an ADRD diagnosis, reflecting a condition with higher healthcare needs, is associated with later-life outmigration among the island’s Medicare beneficiaries. Despite the high ADRD prevalence, Puerto Rico’s social support networks and healthcare system are much more limited than those in other parts of the United States. This makes disease management challenging for patients and families, contributing to later-life outmigration. Traditionally, extended families provide care for older adults, yet by 2007, half of older adults had at least one child abroad. Approximately 700,000 more working-age adults have left Puerto Rico since the late 2000s, weakening kin support networks and leaving those without support to navigate aging alone (; ). With chronic poverty and high unemployment rates (; ), outmigration of young adults continues. Today, older adults constitute a quarter of the island’s population (), and seniors themselves had to care for one another after Hurricane Maria (). Access to quality healthcare remains limited. Frail older Puerto Ricans with functional decline experience high numbers of emergency visits and hospitalizations (), and healthcare utilization typically increases after dementia onset (). Dementia patients have multiple chronic conditions, combined with financial austerity measures that restrict healthcare in Puerto Rico, leading to a higher burden on both patients and healthcare professionals (; ). The island’s federal insurance coverage is capped, with Medicare reimbursement rates in the bottom 25th percentile relative to the U.S. mainland and other territories (). Such lower Medicare payments contribute to physician outmigration (). These systemic barriers may lead older Puerto Ricans, especially those with ADRD, to leave the island in search of better healthcare. Defining movement between Puerto Rico and the U.S. mainland is complicated. As a U.S. territory, Puerto Rico’s residents are required to pay Federal Insurance Contributions Act (FICA) taxes and are entitled to Medicare and Medicaid as U.S. citizens (). Puerto Ricans can freely move anywhere in the U.S., so their movements off the island resemble internal migration (). However, when considering the national (not territorial state) boundary crossover, scholars argue that the nature of island-mainland movement extends beyond internal migration due to the island’s territorial status and distinct cultural identity (, ; ). As a dependent territory of the U.S. Metropole (), Puerto Ricans face interwoven opportunities and challenges tied to cultural boundaries and unequal economic development (; ). Culturally, Puerto Rico maintains a unique national identity, and relocation to the mainland, “irse pa’juera (going outside island country),” embodies a deeper cultural dislocation (, p. 362), not experienced in state-to-state migration. Transnational migration, which occurs when migrants maintain ties with their origin or move back and forth, has been proposed to represent this movement (; for the concept, see ; ). Others, however, resist this framing because no international borders are crossed. While debate exists, it is well-established that older Puerto Ricans face unequal access to healthcare and social welfare compared to the rest of the U.S. ().