Bulletin

Bulletin vol. 34 no. 1 | 17 Many articles on aging, like this one, begin with the statistics highlighting the increasing numbers of older adults in countries around the world. In fact, from 2015 to 2050, the number of people over 60 will essentially double, from 12% to 22% (WHO, 2018). Embedded in this increased number of older people is a growing population of people with dementia and those who will provide care for them. The incidence of dementia will likely only increase as those people continue to age in the years beyond 2050, and our communities, governments, and health care systems should be preparing to meet this need. A one-size- fits-all approach will be inadequate as intersecting identities of people with dementia impact their experiences as well as those of their caregivers. The purpose of this piece is to provide some foundational information about the unique needs of lesbian, gay, and bisexual (LGB) older adults as well as transgender and gender non-conforming (TGNC) older adults and their caregivers. Because of life histories laced with discrimination, abuse, ridicule, and harmful medical and psychological therapies, many LGB and TGNC older adults access health care settings at much lower rates than their heterosexual and cisgender peers. They generally express fear about entering institutional settings like nursing homes, even saying they would go back in the closet to hide their sexual or gender identity to protect themselves (Johnson, Jackson, Arnette, & Johnson, 2005). The onset of dementia complicates this picture since by nature of the disease individuals lose the ability to reason through complex situations and become fully dependent on others to meet their basic needs. Because they are less likely to live with a partner or child, and more likely to live alone, LGBT older adults with dementia are therefore more likely to depend on non-family members for increased amounts of care and support (MetLife, 2010). Dementia among Older LGBT Adults Health disparities among LGBT people are well documented, and many of them contribute to increased risk factors for developing cognitive decline in later life. Though prevalence may vary among countries, in general LGBT people have higher risk of poor mental health, isolation, disability, and poverty (Alzheimer's Association & SAGE, 2018; Fredriksen-Goldson, K. I., Kim, H., Barkan, S. E., Muraco, A., & Hoy-Ellis, 2013). One population-based study showed that lesbian and bisexual women had higher rates of cardiovascular disease and obesity, as well as higher rates of diabetes among bisexual men (Fredriksen-Goldson et al., 2013). The same study showed higher rates of harmful health behaviors such as tobacco and alcohol use among LGBT people. Gay and bisexual men as well as TGNC people are at higher risk of HIV/ AIDS. All of these conditions are also risk factors for cognitive decline and development of dementia as well (Alzheimer's Association & SAGE, 2018). Though the literature is currently limited on unique impacts of dementia on LGBT people, some qualitative studies point to some themes. Ageist attitudes generally de-sexualize and homogenize groups of older adults, and therefore sexual minority older adults can easily become invisible. When people with dementia and their partners are asked, they tend to believe that their innate sexual orientation will not change, but their ability to navigate complex decisions about sex and disclosure of sexual behavior and expression can be impacted by cognitive decline (Barrett, Crameri, Lambourne, Latham, & Whyte, 2015). What is at stake is the person's ability to maintain relationships and ways of living that are consistent with their sexual orientation and gender identity. TGNC individuals with dementia may have less control who knows of their gender history and identity, and as the condition worsens their ability to express their gender (e.g., personal grooming and styling, selecting clothing) may decrease as well. It is important to note that if a person's gender expression changes over the course of dementia, this is not to be taken that the person is no longer TGNC, but rather an effect of the cognitive and functional decline associated with dementia (Barrett et al., 2015). Cognitive decline may also decrease capacity to make medical decisions about gender-affirming hormone therapies and surgeries. Supporting LGBT older adults and their caregivers in advanced care planning is an important proactive and preventive step to put in place some protections and wishes for end of life as dementia progresses. Health care professionals such as physicians, neuropsychologists, and other aging services providers can Weston V. Donaldson, Ph.D., ABPP Behavioral Health Specialist, Iora Primary Care Board Certified in Geropsychology Dementia and Caregiving Among Older LGBT Adults

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