Bulletin

18 | Bulletin vol. 34 no. 1 provide people with documentation needed to identify health care decision-making proxies when the person is no longer able to make decisions about their care themselves. Many same-sex couples put in place documents like a living will or other advance directives, but laws and practices vary from country to country which may not honor these documents. Due to potential conflict with family of origin and lack of protection by state, provincial, or federal laws, some older LGBT adults with dementia could be subject to decisions made by family members who are not LGBT- affirming and possibly hostile. LGBT Dementia Caregivers Caregivers of LGBT people with dementia may or may not identify as LGB or TGNC themselves. As with all dementia caregivers, the pre-existing relationship between the caregiver and the care recipient adds unique qualities and challenges to the caregiving experience. Despite legislative and cultural changes in more recent years, many older LGB and TGNC adults still fear the negative impacts of disclosure of their sexual orientation or gender identity. Caregivers can become the gatekeepers and managers of information about a person's sexual and gender histories and relationship status. Some caregivers report worrying that the person with dementia might inadvertently disclose an aspect of their identity or history that puts them at increased risk for discrimination and mistreatment, which then adds to caregiver burden (Barrett et al., 2015). Caregivers also report that heteronormativity in caregiver support services make them feel less likely to access those resources, which further isolates them (Alzheimer's Association & SAGE, 2018). This can result in delaying accessing services and may place increased and prolonged stress on caregivers when they continue caring for a person at home who really needs a higher level of care. An essential source of support for LGBT people is a 'family of choice' which often includes current and former partners, friends, and other supportive people. Unfortunately, not all governments may recognize non-blood relatives as acceptable decision-makers. Depending on what legally recognized documents are drafted, those closest to a person with dementia may not be allowed to make important decisions and instead next of kin who might be discriminatory or hostile might take over decisions to the detriment of the person with dementia and their loved ones. Recommendations for Health Care Professionals • Participate in and advocate for LGBT cultural competency training to increase one's personal comfort and ability to provide an LGBT-affirming environment. • Advocate for LGB- and TGNC-inclusive policies in aging services institutions. • When assessing decision-making capacity, consider how the patient and caregivers' identities impact aspects such as sexual decision-making and expression, medical decisions related to gender transition and maintaining gender expression. • When able, take time to discuss changes in intimacy and sexual expression in intimate relationships as dementia progresses. Be mindful of language that privileges monogamy, heterosexuality, and a binary understanding of gender over diverse relationship models and gender diversity. Instead, seek to understand the relationships of the patient and caregiver and work within their values and identities. • Neuropsychologists and other professionals are encouraged to discuss with their patients how records like reports are used and what information is included in the interest of protecting a person's privacy and preventing inadvertent disclosures of a persons sexual or gender identity against their wishes. • Keep a list of available LGBT affirming resources including groups focused on supporting LGBT older adults, LGBT- affirming facilities, and caregiver resources. References Alzheimer's Assocation & SAGE (2018). Issues brief: LGBT and dementia. Retrieved 11/18/19 from https://www.sageusa.org/resource-posts/issues- brief-lgbt-and-dementia/. Barrett, C., Crameri, P., Lambourne, S., Latham, JR., & Whyte, C. (2015). Understanding the experiences and needs of lesbian, gay, bisexual and trans Australians living with dementia, and their partners. Australasian Journal on Ageing, 34 (2), 34–38. Fredriksen-Goldson, K. I., Kim, H., Barkan, S. E., Muraco, A., & Hoy-Ellis, C. P. (2013). Health disparities among older lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103, 1802-1809. Johnson, M. J., Jackson, N. C., Arnette, J. K., & Koffman, S. D. (2005). Gay and lesbian perceptions of discrimination in retirement care facilities. Journal of Homosexuality, 49, 83–102.
 MetLife Mature Market Institute. (2010). Still out, still aging: The MetLife study of lesbian, gay, bisexual, and transgender baby boomers. New York, NY: Metropolitan Life Insurance Company World Health Organization. (2018). Ageing and Health. Retrieved 12/15/19 from https://www.who.int/news-room/fact-sheets/detail/ageing-and- health.

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