Scoping Literature Review: Experiences of Sexual and Gender Minority Older Adults, With Diagnoses of Dementia, Who Use Residential Long-Term Services and Supports

The number of sexual and gender minority (SGM) older adults utilizing residential long-term supports and services (LTSS) will increase in the forthcoming decades. Paradoxically, while requiring more LTSS services than their non-SGM counterparts, SGM older adults are less likely to access these services, partly due to fears of discrimination. Furthermore, SGM older adults living with Alzheimer's disease and related dementias (AD/ADRD) present unique challenges and opportunities for LTSS facilities. This article provides a scoping review on the intersection between experiences of SGM older adults with AD/ADRD who use residential LTSS. This review identified three themes: (1) the experiences of discrimination among SGM residents in LTSS facilities, (2) the need for comprehensive staff training in residential LTSS to ensure proper care of SGM populations, and (3) the crucial role of inclusive facility policies. As the number of SGM older adults is expected to increase, further research is necessary.

Moderated Mediation Analysis of Structural Stigma and Suicidal Ideation and Behaviors Among Sexual and Gender Minority Adults

Purpose: This study aimed to conduct a moderated mediation analysis to understand further the complex pathways through which structural stigma in the form of transgender sports bans was associated with suicidal ideation and behaviors among sexual and gender minority (SGM) adults. Methods: A cross-sectional survey of 1033 adults who identified as SGM from across the 50 U.S. states and Washington, DC was conducted between January 28 and February 7, 2022. Distal discrimination distress was the mediation variable; individual resilience and social resources were the moderation variables. Familiarity with transgender sports bans represented structural stigma. The conditional process analysis was applied to build a moderated mediation model. Both conditional direct and indirect effects were computed by estimated coefficients. All models were based on linear regression. Results: Our final model explained nearly half (46%) of the variation in suicidal ideation and behaviors between those SGM adults familiar and those not familiar with transgender sports bans. Social resources significantly moderated the conditional indirect effect of distal discrimination distress (adjusted estimate = -0.23; 95% confidence interval = -0.37 to -0.08). Conclusion: Both discrimination distress and social resources influenced the association between structural stigma as measured by familiarity with transgender sports bans and suicidal ideation and behaviors among SGM adults. Findings support the need for future research examining the pathway between structural stigma and suicidal ideation and behaviors among SGM adults and how minority stress, social safety, and other constructs shape this pathway.

Cognitive Impairment in Sexual and Gender Minority Groups: A Scoping Review of the Literature

Purpose: The purpose of this review was to synthesize evidence on differences in cognitive impairment by sexual orientation/gender identity (SOGI) status. Methods: A scoping review of the literature was conducted. Five databases (PubMed/Medline, Cumulated Index to Nursing and Allied Health Literature, Web of Science, PsycInfo, and Embase) were searched for primary articles comparing incidence or prevalence of cognitive impairment among sexual and gender minority (SGM) groups versus non-SGM groups. Two reviewers independently screened articles and conducted risk-of-bias assessment on eligible articles. Results: Fifteen primary studies were eligible. Most studies (n = 13) were cross-sectional, with moderate to critical risk of bias. Among eight studies examining self-reported cognitive impairment, seven reported a higher prevalence among some SGM groups versus non-SGM groups. Among seven studies using objective measures of cognitive impairment, three examined prevalence of clinician-documented diagnosis of dementia, of which two reported a higher prevalence specifically among transgender versus cisgender individuals. Among the other four studies examining objective measures, two reported poorer cognitive performance or memory, one reported better performance, and another reported no difference. Comparisons across studies were challenging due to inconsistencies in how SOGI and cognitive impairment were operationalized, and the factors used for statistical adjustment; some studies adjusted for putative intermediary factors that potentially explain differences in cognitive impairment. Conclusions: Whereas most published studies identified a positive relationship between SOGI status and self-reported cognitive impairment, evidence is mixed with regard to objective cognitive performance. Well-designed longitudinal, observational studies are needed, using objective measures of cognitive function, with careful consideration of confounding versus intermediary risk factors.

Characterizing Multimorbidity Prevalence and Adverse Outcomes in Ethnically and Culturally Diverse Sub-Populations in India: Gaps, Opportunities, and Future Directions

India is a large middle-income country and has surpassed China in overall population, comprising 20% of the global population (over 1.43 billion people). India is experiencing a major demographic shift in its aging population. Chronic diseases are common among older adults and can be persistent over the life course, lead to the onset of disability, and be costly. Among older adults in India, the existence of multiple comorbid chronic conditions (i.e., multimorbidity) is rapidly growing and represents a burgeoning public health burden. Prior research identified greater rates of multimorbidity (e.g., overweight/obesity diabetes, hypertension, cardiovascular disease, stroke, and malignancies) in minority populations in the United States (U.S.); however, limited studies have attempted to characterize multimorbidity among older adult sub-populations residing in India. To address this gap, we conducted a narrative review of studies on multimorbidity using the data from the Longitudinal Aging Study of India (LASI), the largest nationally representative longitudinal survey study of adults in India. Our definition of multimorbidity was the presence of more than two conditions in the same person. Our findings, based on 15 reviewed studies, aim to (1) characterize the definition and measurement of multimorbidity and to ascertain its prevalence in ethnically and culturally diverse sub-populations in India; (2) identify adverse outcomes associated with multimorbidity in the Indian adult population; and (3) identify gaps, opportunities, and future directions.

Use of Digital Health Resources by Sexual and Gender Minority Caregivers of Older Adults: Findings From the 2020 Caregiving in the U.S. Survey

We applied Andersen's Behavioral Model of Health Services Use to investigate the health needs and use of digital health resources among sexual and/or gender minority (SGM) caregivers. Data were from the Caregiving in the U.S. 2020 survey. Regression analyses were used to describe associations between predisposing, enabling, and need factors and usage of digital health resources. SGM caregivers provided more hours of care per week, reported higher levels of care intensity, and reported higher physical, emotional, and financial strain compared with non-SGM caregivers. Regression analyses indicated SGM status was a significant predictor of overall use of digital health resources. Younger caregivers, racial minority caregivers, those providing higher levels of care, and those reporting a poorer health status were more likely to use digital health resources. Digital health resources may be useful tools for SGM caregivers of older adults. More research is needed to investigate the reasons SGM caregivers use these resources.

Risk of Neuropsychiatric Symptoms Among People Who Develop Cognitive Impairment With and Without a History of Post-traumatic Stress Disorder

We aimed to prospectively assess the change in neuropsychiatric symptoms among people who develop cognitive impairment and have a history of post-traumatic stress disorder (PTSD). We analyzed longitudinal data from the National Alzheimer's Coordinating Center Unified Data Set (March 2015 to December 2021). Analyses included individuals who were cognitively normal and who had nonmissing assessment of PTSD at the initial visit and had at least 1 follow-up visit with cognitive impairment. We compared the difference in the mean neuropsychiatric symptom score at the first Unified Data Set visit versus the first visit with a Clinical Dementia Rating of 0.5 between those with and without a history of PTSD. The mean neuropsychiatric symptom score change did not differ between those with and without a history of PTSD (1.06 vs. 0.77, respectively; P =0.79). The null results found in this study warrant future research. Several methodological limitations might explain these results.

Synthesizing Best Practices to Promote Health Equity for Older Adults Through Community-Engaged Research

Achieving health equity requires creating evidence that reflects the nuance and diversity of experiences among populations disproportionately impacted by age- and race-related disparities. Community-engaged research (CEnR) is one way to pursue equity in research on health and aging to ensure the relevance and translational potential of findings. The current review synthesizes best practices regarding CEnR that promote health equity among older adults, including an overview of CEnR, benefits, and fundamental principles, and three research exemplars from the authors' CEnR. Finally, we discuss these best practices and considerations for advancing CEnR to reduce health disparities experienced by historically underserved older adults and their families. [Research in Gerontological Nursing, 17(1), 9-16.].

Medical Mistrust Mediates the Relationship Between Nonconsensual Intersex Surgery and Healthcare Avoidance Among Intersex Adults

BACKGROUND

Intersex individuals experience poor health due, in part, to healthcare avoidance. Nonconsensual intersex surgery may contribute to medical mistrust and avoidance among intersex populations.

PURPOSE

The purpose of this study was to explore the relationship between nonconsensual surgery and healthcare avoidance among intersex populations and to examine if medical mistrust mediates this relationship.

METHODS

Data for this cross-sectional study were collected in 2018 and analyzed in 2022. Participants completed a survey collecting information on demographics, medical mistrust, history of nonconsensual surgery, and history of postponing healthcare. One hundred nine participants with valid responses to all regression model variables were included in the study. Multivariable logistic regression models controlling for age, race, and income, examined the relationship between nonconsensual surgery and postponing preventive and emergency healthcare. Mediation analyses of cross-sectional data examined whether medical mistrust mediated the relationship between nonconsensual surgery and postponing preventive and emergency healthcare.

RESULTS

Mean medical mistrust score was 2.8 (range = 1-4; standard deviation = 0.8), 49.7% of participants had nonconsensual surgery in their lifetime, 45.9% postponed emergency healthcare, and 61.5% postponed preventive healthcare in their lifetime. Nonconsensual surgery was associated with increased odds of delaying preventive (adjusted odds ratio [AOR] = 4.17; confidence interval [CI] = 1.76-9.88; p = .016) and emergency healthcare (AOR = 4.26; CI = 1.71-10.59; p = .002). Medical mistrust mediated the relationship between nonconsensual surgery and delaying preventive (indirect effect = 1.78; CI = 1.16-3.67) and emergency healthcare (indirect effect = 1.66; CI = 1.04-3.30).

CONCLUSIONS

Nonconsensual surgery contributed to healthcare avoidance in this intersex population by increasing medical mistrust. To decrease healthcare avoidance, intersex health promotion interventions should restrict nonconsensual surgery and build trust through trauma-informed care.

A Focus on Aging, HIV/AIDS, and Neurocognitive Challenges: Examining Southern Nevada HIV Sector Providers' Awareness and Prospective Roles

Although abundant research has been carried out to investigate the underlying mechanisms that may cause neurocognitive challenges among middle-aged and older people living with HIV/AIDS (PLWH), to monitor the prevalence rates of HIV-related neurocognitive deficits, and to identify factors related to the improvement of diagnostic screening tools, classification and nosology, and clinical and rehabilitative treatment of HIV-Associated Neurocognitive Disorder (HAND); to date, there have been only a few studies that have explored and examined the awareness and work experiences HIV sector healthcare and service providers have related to HAND. To address this research gap, we conducted a qualitative, community-based participatory research study and interviewed 12 HIV sector providers in Southern Nevada, USA, from January to April 2022. After performing a thematic analysis of our interviews, we were able to identify two major themes and several sub-themes. Under our first major theme, provider awareness and knowledge, we identified four sub-themes: (1) prior knowledge and current awareness; (2) lived experiences of patients and clients with neurocognitive challenges; (3) lack of knowledge as a barrier to providing needed care; and (4) continuing education and professional development. Under our second major theme, prospective provider roles, we identified three sub-themes: (1) early detection; (2) direct and practical support; and (3) appropriate and timely referrals. In this article, we discuss our findings and lessons learned from our study, as well as their implications for the future work of researchers and providers in the HIV sector related to improving care and support for people aging with HIV/AIDS and experiencing neurocognitive challenges.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science

INTRODUCTION

Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators.

METHODS

An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings.

RESULTS

A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions.

DISCUSSION

A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities.

HIGHLIGHTS

Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Perceived Discrimination in Health Care for LGBTQIA+ People Living With Parkinson's Disease

OBJECTIVES

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, other non-cisgender, and non-heterosexual identities (LGBTQIA+) experience discrimination when accessing health care. We investigated specific experiences of LGBTQIA+ people with Parkinson's disease (PwP) as they are less known.

METHODS

Data were obtained from Fox Insight for PwP identifying as LGBTQIA+ (n = 210), cisgender, heterosexual women (n = 2,373) or cisgender, heterosexual men (n = 2,453). Discrimination in Medical Settings Scale responses and reports of whether gender identity or sexual orientation played a role in the perceived discrimination were compared across the groups.

RESULTS

Parkinson's diagnosis age was the youngest for LGBTQIA+ PwP. Despite similar levels of education with cisgender, heterosexual men, LGBTQIA+ people had lower levels of income and were more likely to be unemployed. Cisgender, heterosexual women and LGBTQIA+ PwP reported greater discrimination than cisgender, heterosexual men. Compared to cisgender, heterosexual men; LGBTQIA+ people (25%) and cisgender, heterosexual women (20%) were more likely to report their gender affected how they were treated; LGBTQIA+ PwP (19%) were more likely to report their sexual orientation affected how they were treated.

DISCUSSION

Women and LGBTQIA+ PwP may be at a higher risk for discrimination in medical settings. Facing disparities while receiving health care based on gender or sexual orientation can affect the health care utilization of PwP. Health care providers should consider their behaviors and interactions with PwP to ensure inclusive and welcoming health care environments.

The structural and social determinants of Alzheimer's disease related dementias

INTRODUCTION

The projected growth of Alzheimer's disease (AD) and AD-related dementia (ADRD) cases by midcentury has expanded the research field and impelled new lines of inquiry into structural and social determinants of health (S/SDOH) as fundamental drivers of disparities in AD/ADRD.

METHODS

In this review, we employ Bronfenbrenner's ecological systems theory as a framework to posit how S/SDOH impact AD/ADRD risk and outcomes.

RESULTS

Bronfenbrenner defined the "macrosystem" as the realm of power (structural) systems that drive S/SDOH and that are the root cause of health disparities. These root causes have been discussed little to date in relation to AD/ADRD, and thus, macrosystem influences, such as racism, classism, sexism, and homophobia, are the emphasis in this paper.

DISCUSSION

Under Bronfenbrenner's macrosystem framework, we highlight key quantitative and qualitative studies linking S/SDOH with AD/ADRD, identify scientific gaps in the literature, and propose guidance for future research.

HIGHLIGHTS

Ecological systems theory links structural/social determinants to AD/ADRD. Structural/social determinants accrue and interact over the life course to impact AD/ADRD. Macrosystem is made up of societal norms, beliefs, values, and practices (e.g., laws). Most macro-level determinants have been understudied in the AD/ADRD literature.

"Going Back in the Closet": Addressing Discrimination Against Sexual and Gender Minority Residents in Long-Term Services and Supports by Providing Culturally Responsive Care

Sexual and gender minority (SGM) older adults face discrimination in long-term services and supports (LTSS). Yet, SGM older adults use LTSS disproportionately higher relative to their non-SGM counterparts. The discrimination is compounded by existing disparities, resulting in worse health outcomes and well-being for SGM older adults. Guided by socioecological model, we posit that training LTSS staff in SGM responsive care and implementing SGM anti-discrimination policies will be needed to improve care. Considering accessibility and turnover challenges, training should be online, interactive, and easily accessible. Studies that assess interventions for SGM responsive care are needed to guide policy and practice.

Transgender Adults From Minoritized Ethnoracial Groups in the U.S. Report Greater Subjective Cognitive Decline

OBJECTIVES

Investigate subjective cognitive decline (SCD) among 4 study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

METHODS

Data from the 2015-2020 Behavioral Risk Factor Surveillance System were used in a modified case-control approach to perform an intercategorical intersectional study. Each transgender participant was matched to 2 cisgender men and 2 cisgender women, on state, ethnoracial identity, and age. Multivariable logistic regressions modeled SCD odds by group and post hoc contrasts estimated pairwise odds ratios comparing the SCD odds for each combination of groups.

RESULTS

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%). After accounting for age, education, and survey year, the odds of SCD were higher in minoritized ethnoracial transgender when compared to White cisgender (adjusted odds ratio [aOR] = 2.51, 95% confidence interval [CI]: 1.59-3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16-3.09). The odds of SCD were higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20-2.30).

DISCUSSION

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity.

Discordance in chromosomal and self-reported sex in the UK Biobank: Implications for transgender- and intersex-inclusive data collection

There is growing need to distinguish between sex and gender. While sex is assigned at birth, gender is socially constructed and may not correspond to one's assigned sex. However, in most research studies, sex or gender is assessed in isolation or the terms are used interchangeably, which has implications for research accuracy and inclusivity. We used data from the UK Biobank to quantify the prevalence of disagreement between chromosomal and self-reported sex and identify potential reasons for discordance. Among approximately 200 individuals with sex discordance, 71% of discordances were potentially explained by the presence of intersex traits or transgender identity. The findings indicate that when describing sex- and/or gender-specific differences in health, researchers may be limited in their ability to draw conclusions regarding specific sex and/or gender health information.

Alzheimer's Disease Services, Staffing, and Outcomes in Adult Day Health Centers

OBJECTIVES

Increasing rates of Alzheimer disease and related dementia (ADRD) has resulted in greater reliance on adult day health centers (ADHCs) and their skilled workforce. Little is known about staffing in ADHCs that provide ADRD services compared with ADHCs that do not. This study examines whether there are differences in staffing between ADHCs that offer ADRD services versus those that do not, and whether the percentage of ADHC participants with ADRD is associated with staffing levels. It also examines whether staffing levels and provision of ADRD services are associated with participant outcomes.

DESIGN

Cross-sectional analysis of secondary survey data.

SETTING AND PARTICIPANTS

We used facility-level data from the 2014 National Post-acute and Long-term Care Study Adult Day Services Center module. This survey is completed by administrators of ADHCs, who provide information about their ADHC's organization, services, participants, sources of payment, staffing, and participant outcomes.

METHODS

Bivariate comparisons and multivariate regressions were used to compare scope of services, staffing, and participant outcomes for ADHCs that offered ADRD programs compared with those that did not.

RESULTS

ADHCs with ADRD programs had similar average daily attendance, less revenue from Medicaid and self-payment, and greater proportions of Black and female participants. ADHCs with ADRD programs had similar staff hours per participant day for all staff categories; licensed nurse staffing increased and social worker staffing decreased with the proportion of participants with ADRD. Staffing had significant associations with participant outcomes.

CONCLUSIONS AND IMPLICATIONS

ADHCs that have more participants with ADRD have greater staffing of licensed nurses but fewer social workers. Participant outcomes are associated with staffing, but the results suggest that there are unmeasured dimensions of participant risk that confound the relationship.

Cognitive Aging with Dementia, Mild Cognitive Impairment, or No Impairment: A Comparison of Same- and Mixed-Sex Couples

BACKGROUND

Lesbian and gay older adults have health disparities that are risk factors for Alzheimer's disease, yet little is known about the neurocognitive aging of sexual minority groups.

OBJECTIVE

To explore cross-sectional and longitudinal dementia outcomes for adults in same-sex relationships (SSR) and those in mixed-sex relationships (MSR).

METHODS

This prospective observational study utilized data from the National Alzheimer's Coordinating Center Uniform Data Set (NACC UDS) collected from contributing Alzheimer's Disease Research Centers. Participants were adults aged 55+ years at baseline with at least two visits in NACC UDS (from September 2005 to March 2021) who had a spouse, partner, or companion as a co-participant. Outcome measures included CDR® Dementia Staging Instrument, NACC UDS neuropsychological testing, and the Functional Activities Questionnaire. Multivariable linear mixed-effects models accounted for center clustering and repeated measures by individual.

RESULTS

Both MSR and SSR groups experienced cognitive decline regardless of baseline diagnosis. In general, MSR and SSR groups did not differ statistically on cross-sectional or longitudinal estimates of functioning, dementia severity, or neuropsychological testing, with two primary exceptions. People in SSR with mild cognitive impairment showed less functional impairment at baseline (FAQ M = 2.61, SD = 3.18 vs. M = 3.97, SD = 4.53, respectively; p < 0.01). The SSR group with dementia had less steep decline in attention/working memory (β estimates = -0.10 versus -0.18; p < 0.01).

CONCLUSION

Participants in SSR did not show cognitive health disparities consistent with a minority stress model. Additional research into protective factors is warranted.

A systematic review of measures of gender and biological sex: Exploring candidates for Alzheimer's disease and related dementias (AD/ADRD) research

Background

Gender and biological sex are social and structural determinants of health and umbrella concepts encompassing many distinct attributes. This systematic review summarizes measures of gender and biological sex published in the biomedical literature. The goal was to identify measures that may be useful to researchers studying Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD).

Methods

A search of PubMed, Embase, and PsycINFO (ProQuest platform) databases from 2000 to 2021 identified 1454 articles, which were then screened by five independent reviewers. Measures of gender and biological sex are summarized according to theoretical commitments and psychometric properties.

Results

Twenty-nine measures were identified that assessed gender-related constructs, and 4 were identified that assessed biological factors. Self-report instruments characterized aspects of gender, such as gender stereotypes, norms, and ideologies. One measure was developed with a focus on older adults (65+ years).

Discussion

We offer recommendations to guide measurement of gender in AD/ADRD research, including how the use of specific existing measures may help advance AD/ADRD research. The lack of gender measures for older adults limits AD/ADRD research. New measures may be needed to address lifespan and generational differences in gender factors.

Highlights

A review of articles identifies 29 measures of gender in biomedical research.Gender is captured using multidimensional, self-reported concepts.One measure was developed with a focus on older adults (65+).

Inclusive Care Practices and Policies Among Sexual and Gender Minority Older Adults

As the health care and well-being of sexual and gender minority (SGM; i.e., lesbian, gay, bisexual, and/or transgender or gender non-binary) people in the United States receive federal and local-level attention, SGM older adults and caregivers continue to be left out of important health policy and care conversations. The current article describes policy issues and affirmative strategies related to inclusive care practices among SGM older adults and caregivers. In addition to the broader policies considered related to health and well-being, we include a discussion of local-level policy strategies to mitigate discrimination and promote inclusive care for SGM older adults and caregivers. [Journal of Gerontological Nursing, 48(12), 6-15.].

Feasibility of the Savvy Caregiver Program for LGBTQ+ Caregivers of People Living with Alzheimer's Disease and Related Dementias

Nearly 350,000 lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) adults in the U.S. are currently living with Alzheimer's disease and related dementias (ADRD). Informal caregivers face challenges impacting their ability to access and receive adequate and inclusive care for LGBTQ+ persons living with ADRD. The purpose of this study was to determine the feasibility and acceptability of the Savvy Caregiver Program for caregivers of LGBTQ+ individuals living with ADRD. Data for this secondary analysis come from caregivers (n = 17) who completed 6 sessions of the Savvy program. Caregivers were very satisfied with tailored program activities. Analyses of trends suggest non-significant increases in positive aspects of caregiving and decreases in caregiver burden and depressive symptoms. This is the first known study assessing the feasibility of the Savvy Caregiver Program for caregivers of LGBTQ+ individuals living with ADRD. Future research on the Savvy Caregiver Program for caregivers of LGBTQ+ people living with ADRD is needed.

Moderating Effect of Community and Individual Resilience on Structural Stigma and Suicidal Ideation among Sexual and Gender Minority Adults in the United States

BACKGROUND

Structural stigma in the form of discriminatory laws and policies impacts the mental health of sexual and gender minorities, especially with regard to suicidality. However, this relationship could be moderated by resilience. The past two years has brought anti-SGM legislation, particularly transgender sports bans, at the state level in the United States into focus. This study aims to understand if the relationship between familiarity with transgender sports bans (proposed or enacted) and suicidality was moderated by individual or community resilience.

METHODS

This was a cross-sectional study of survey data collected from a national sample of 1033 SGM adults in the United States between 28 January and 7 February 2022. Univariate and multivariate moderation analyses were used.

RESULTS

In the univariate analyses and the final model, community resilience moderated the relationship between structural stigma and suicidality (p = 0.0002); however, individual resilience did not (p = 0.0664).

CONCLUSION

Interventions to bolster community resilience may attenuate the negative mental health impacts of structural stigma and are warranted, along with concerted efforts to minimize structural stigma in the form of discriminatory laws and policies targeting people who are SGM.

Divergent patterns of cognitive deficits and structural brain alterations between older adults in mixed-sex and same-sex relationships

Background

Sexual minority (SM) older adults experience mental health disparities. Psychiatric disorders and neuropsychiatric symptoms (NPS) are risk factors for cognitive decline. Although older people in same-sex (SSR) compared to mixed-sex relationships (MSR) perform more poorly on cognitive screening tests, prior studies found no differences in rates of dementia diagnosis or neuropsychological profiles. We sought to explore the role of NPS on neurocognitive outcomes for SM populations. We compared cognitive performance and structural brain parameters of older adults in SSR and MSR.

Methods

Data were originally collected at Alzheimer's Disease Research Centers (ADRCs). Inclusion criteria were: age of 55+ years, a study partner identified as a spouse/partner, and availability of T1-MRI brain volumes/thickness. Participants were labeled as either SSR or MSR based on their/their co-participant's reported sex. We identified 1,073 participants (1,037 MSR−555 cognitively unimpaired [CU]; 36 SSR−23 CU) with structural MRI data, Mini-Mental State Exam (MMSE), and Neuropsychiatric Inventory Questionnaire (NPI-Q) scores. A subset of the overall sample completed comprehensive neuropsychological assessment (n = 939; 908 MSR−494 CU; 31 SSR−22 CU). Covariates included in statistical models were age, sex, education, total intracranial volume, and apolipoprotein E genotype.

Results

Multivariate general linear models showed significant diagnosis-by-relationship interaction effects on the left parahippocampal gyrus volume. After stratification by relationship group, only cognitively impaired (CI) MSR had significantly smaller left parahippocampal volumes than MSR-CU. The SSR group showed better episodic memory performance. Severity of neuropsychiatric symptoms was negatively associated with volume/thickness of bilateral fronto-temporal areas and with MMSE scores, predominantly in the MSR group.

Conclusion

In our study, MSR participants presented with a more compromised cognitive profile than SSR participants. MSR-CI participants showed significantly smaller left medio-temporal volumes, a neural signature of AD. Neuropsychiatric symptoms predicted smaller fronto-temporal volumes in the MSR more consistently than in the SSR group. These findings may be due to unexplored protective factors against cognitive decline in SM elders. Indeed, social support has been proposed as a protective factor warranting future investigation.

Subjective Cognitive Decline Associated with Discrimination in Medical Settings among Transgender and Nonbinary Older Adults

Background: Transgender and nonbinary (TNB) individuals report greater subjective cognitive decline (SCD) compared to non-TNB people. SCD involves self-reported problems with memory and thinking and is a potential risk for Alzheimer’s disease and related dementias (ADRD). We explored psychosocial factors, such as discrimination in medical settings, associated with SCD in a sample of TNB older adults. Methods: We utilized cross-sectional data on aging health, SCD (memory complaints and worsening memory in the past year), and discrimination in medical settings from The PRIDE Study for LGBTQ+ adults aged 50+ including TNB adults (n = 115). Associations were tested using multivariate logistic regression. Results: Nearly 16% of TNB participants rated their memory as poor/fair, and 17% reported that their memory was worse than a year ago. TNB older adults with SCD were more likely to report experiencing discrimination in medical settings. After adjustment, those reporting discrimination in medical settings had 4.5 times higher odds of reporting worsening memory than those who did not (OR: 4.5; 95%-CI: 1.5–13.2; p = 0.006), and 7.5 times more likely to report poor/fair memory (OR: 7.49; 95%-CI: 1.7–32.8; p = 0.008); Conclusions: TNB older adults reported high frequencies of SCD and discrimination in medical settings. Further research exploring affirmative cognitive screening and healthcare services is needed.

Functional Limitations and Access to Long-Term Services and Supports Among Sexual Minority Older Adults

Objective: Little is known about sexual minority (SM) older adults' activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations and their subsequent access to long-term services and supports (LTSS). Methods: We analyzed cross-sectional data from the 2016 Health and Retirement Study limited to individuals ≥50 years old. Bivariate analyses were performed to examine 1) sexual identity differences in the prevalence of ADL/IADL limitations and 2) associations of sexual identity with having ADL/IADL limitations and having access to help with ADL/IADL limitations. Results: Our sample consisted of 3833 older adults, 6% (n = 213) were SM. Compared to heterosexual participants, bisexual older adults had greater reports of ADL/IADL limitations (20.9% vs. 35.9%, p = 0.013). Among those who reported having ADL/IADL limitations (n = 803), there were no sexual identity differences in accessing help for ADL/IADL limitations (p = .901). Discussion: Our findings contribute to the limited research on LTSS access among SM older adults.

Advancing Gerontological Health Research With Sexual and Gender Minorities Across the Globe

The current article presents results of a scoping review of international research on the health and health care needs of sexual and gender minority (SGM) older adults. Electronic databases and related resources were used to identify empirical and review studies published during the past 10 years. We reviewed 33 peer-reviewed articles from 19 countries. Findings were organized using the SGM Health Disparities Research Framework, which highlights factors at individual, interpersonal, community, and societal levels that impact health. Overall, historic and current environmental factors, including stigma, discrimination, and social exclusion, played an important role in SGM older adults' health, health care access, and use of related aging and social services. There is a critical need for training and future research, and health professionals are needed to advance gerontological health and health care research and improve the health and care of SGM older adults globally. [Journal of Gerontological Nursing, 48(4), 13-20.].

A Comparative Analysis of Family Quality of Life Between Heterosexual and Sexual Minority Caregivers of People with Dementia

Providing care for someone with Alzheimer's disease or related dementias (ADRD) is associated with significant physical and mental strain affecting quality of life among caregivers. However, little attention has been given to sexual minority (SM; lesbian, gay, bisexual, queer) people caring for those with ADRD. In this cross-sectional study, we used psychosocial measures to describe the characteristics and family quality of life of SM and heterosexual caregivers for people with ADRD. SM caregivers were significantly younger and more frequently reported full or part-time employment compared with their heterosexual counterparts. Lesbian and bisexual caregivers reported more difficulty in paying for everyday basics. After controlling for demographic covariates, SM caregivers had significantly higher family quality of life scores compared with heterosexual caregivers. This study is among the first to compare family quality of life between SM and heterosexual caregivers. Findings can guide development of targeted interventions for SM caregivers.

Feasibility of the Savvy Caregiver program for care providers of LGBTQ adults living with Alzheimer's disease and related dementias

BACKGROUND

By 2030, there will be nearly six million lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) older adults aged 50 and older in the U.S.; this number will more than double by 2050. Approximately 350,000 LGBTQ older adults in the U.S. currently have Alzheimer's disease and related dementias (ADRD), with projections nearing 1 million by 2030. LGBTQ older adults face distinct challenges impacting their ability to receive adequate and inclusive care, as well as services for informal caregivers due to living alone, the inability to rely on traditional family supports, higher risks for disability, and experiencing discrimination when seeking aging-related social services.

METHODS

We partnered with the Los Angeles LGBT Center, Senior Services to evaluate the: 1) Adaptation of the Savvy Caregiver training program for care providers of LGBTQ older adults living with AD; and 2) Determine the feasibility and acceptability of the Savvy program. Data comes from caregivers (n=18) who completed the 6 session, 12-hour training for Savvy.

RESULTS

The average age of care providers was 66 (range: 52-82), and over half (56%) identified as a LGB and 6% as transgender. Overall, care providers were very satisfied with the overall program, strategies, information, and activities of the tailored Savvy Caregiver program. For instance, all participants (100%) reported being more knowledgeable of dementia care and that they would recommend the program to others. Nearly 90% of participants found the content to be relevant to their personal situation, reported gaining new skills, and felt that the class format/number of sessions was appropriate.

DISCUSSION

We developed a community partnership with the Los Angeles LGBT Center on the needs of LGBTQ older adults living with ADRD and their care providers. This is the first known study regarding the adaptability and feasibility of the Savvy Caregiver program for care providers of LGBTQ older adults living with ADRD. There is need for additional research to promote culturally relevant aging services and behavioral interventions for care providers of LGBTQ older adults living with ADRD.

Measuring Sex and Gender in Aging and Alzheimer's Research: Results of a National Survey

OBJECTIVE

Differences between men and women are common in published research on aging and Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD). What do these differences mean? To answer this, rigorous measurement is needed. We investigated current methods for measuring sex/gender in aging and AD/ADRD cohort studies.

METHOD

An online survey was sent to NIA-funded Alzheimer's Disease Research Centers (ADRCs) (n=38) and investigator-initiated cohort studies (n=38) to assess practices around enrollment of men and women and measurement of sex and gender.

RESULTS

The response rate was 65.8% (n=50). All enrolled men and all but two investigator-initiated studies enrolled women. Most cohorts (43/50) had no documented definitions for categories of "men" or "women". Over 85% of cohorts relied solely on self-report questions to capture sex/gender data (n=43/50). Issues with administration were also identified (n=7).

DISCUSSION

Our findings identify gaps in current approaches used to measure sex and gender in aging and AD/ADRD research. We discuss opportunities to bridge these gaps and advance measurement of sex and gender in aging and AD/ADRD research. Changes are needed to ensure inclusion and representation of sociocultural diversity in research samples, and consistency in data collection in aging and AD/ADRD research.

Creating a Minority Stress Index to Examine Mental Health Impacts of Discrimination Among Transgender and Gender Nonbinary Adults

Purpose: This study analyzed the differing impact of discrimination on mental health outcomes among transgender and gender nonbinary (TGNB) adults. Methods: We utilized data from the 2015 U.S. Transgender Survey. Mental health outcomes included psychological distress, suicidal thoughts, and a suicide attempt. To determine the impact of discrimination categories, we utilized a weighted quantile sum (WQS) regression approach to create a minority stress index (MSI). The MSI included seven discrimination categories: interpersonal, workplace, health care, religious, public services, housing, and verbal and/or physical attack. Results: The average psychological distress score was 10.65 points (standard deviation = 6.05), range: 0-24. Nearly 82% and 39% of TGNB adults reported ever having suicidal thoughts and a suicide attempt, respectively. Verbal and/or physical attack and religious discrimination had the most significant weights in the MSI for each mental health outcome. Every 0.1 point increase in the MSI significantly increased the psychological distress score by 0.468 points (95% confidence interval [CI] = 0.434-0.503; p < 0.0001), and the odds of suicidal thoughts and a suicide attempt by 27.07% (95% CI = 24.15-30.05; p < 0.0001) and 28.46% (95% CI = 26.34-30.61; p < 0.0001), respectively. Conclusion: This study introduces a novel method for analyzing experiences of minority stress in health disparities research. By using the WQS regression method, we were able to parse out the indicators of minority stress that had the greatest impact on mental health outcomes. There is a continued need for interventions to mitigate the high rates of suicidality and psychological distress among TGNB populations.

Subjective cognitive decline higher among sexual and gender minorities in the United States, 2015-2018

INTRODUCTION

Subjective cognitive decline (SCD) represents self-reported problems with memory, a possible early sign of dementia. Little is known about SCD among sexual and gender minority (SGM) adults who identify as lesbian, gay, bisexual, and/or transgender or gender non-binary.

METHODS

Data were weighted to represent population estimates from 25 states' 2015-2018 Behavioral Risk Factor Surveillance System to describe SCD in adults ≥45 years by SGM status. Logistic regression tested associations between demographic and health conditions.

RESULTS

SCD prevalence was higher in SGM (15.7%; 95% confidence interval [CI]:13.1-18.2) than in non-SGM adults (10.5%; 95% CI:10.1-10.9; P < .0001). SGM adults with SCD were also more likely to report functional limitations due to SCD than non-SGM adults with SCD, 60.8% versus 47.8%, P = .0048. Differences in SCD by SGM status were attenuated after accounting for depression.

DISCUSSION

Higher prevalence of SCD in SGM adults highlights the importance of ensuring inclusive screenings, interventions, care services, and resources for SGM adults.

Sexual and Gender Minority Health in Neurology: A Scoping Review

Importance

Little is known about the neurologic health needs of sexual and gender minority (SGM) individuals, and existing research indicates health care disparities for this group.

Objective

To describe the current state of science in SGM neurology and highlight areas of knowledge and gaps to guide future research.

Evidence Review

All articles published before April 12, 2020, in PubMed, Embase, Web of Science, PsycInfo, CINAHL, and BIOSIS Previews were searched using a search string encompassing SGM descriptors and neurologic disorders. A total of 8359 items were found and entered into EndNote, and 2921 duplicates were removed. A blind title and abstract review was performed followed by full-text review in duplicate, with conflicts settled through consensus, to identify 348 articles eligible for data abstraction. Articles presenting primary data about an identified adult SGM population addressing a clinical neurology topic were included. Descriptive statistics were used for abstracted variables.

Findings

Of 348 studies, 205 (58.9%) were case reports or series, 252 (72.4%) included sexual minority cisgender men, and 247 (70.9%) focused on HIV. An association was found between autism spectrum disorder and gender dysphoria in 9 of 16 studies (56.3%), and a higher risk of ischemic stroke in transgender women was shown in other studies. Literature in neuroinfectious disease, the most common topic, largely focused on HIV (173 of 200 studies [86.5%]). Findings in other neurologic topics were limited by lack of data.

Conclusions and Relevance

In this rigorous compendium of SGM neurology literature, several deficiencies were found: most studies focused on a limited breadth of neurologic pathology, included only a portion of the overall SGM community, and did not assess other aspects of sociodemographic diversity that may contribute to disparities in health care access and outcomes among SGM individuals. Expanding neurologic research to include broader representation of SGM individuals and incorporating sociodemographic factors, like race/ethnicity and socioeconomic status, are essential steps toward providing equitable neurologic care for this community.

Characteristics of Sexual and Gender Minority Caregivers of People With Dementia

Objectives: Given what little is known about the experiences of sexual and gender minority (SGM) caregivers of people with Alzheimer's disease and related dementias (ADRD), the aim of the current study was to describe psychosocial measures among these caregivers. Methods: We used an online survey and social media recruitment strategies. Results: Of 286 caregivers, the majority were gay men. Most respondents were white, with a third identifying as Latino American. The plurality of caregivers identified as a spouse/partner and were providing care for someone who identified as a sexual minority; one-fifth cared for someone transgender. Sexual orientation, perceived stress, caregiver stigma, and microaggressions were psychosocial factors associated with family quality of life and depressive symptoms in the caregivers. Discussion: This study is the first to provide a focused description of the characteristics and psychosocial needs of SGM caregivers of someone with ADRD, supporting development of targeted interventions for this population.

Predictors of Mind-Body Therapy Use Among Sexual Minority Older Adults

Introduction: Sexual minority (SM; lesbian, gay, bisexual) older adults age 50+ experience a higher prevalence of chronic disease and disability, as well as a poorer physical and mental health status, compared with their heterosexual peers. Many adults use complementary and integrative therapies, particularly mind-body therapies, as health-enhancing approaches and to support well-being. However, no study to date has examined the use of mind-body therapies among SM older adults. Materials and Methods: Data were from the 2017 National Health Interview Survey. Descriptive and summary statistics were calculated to describe use of mind-body therapies by SM older adults (aged 50+). The authors also tested associations between use of mind-body therapies and health and well-being among SM older adults and compared associations with their non-SM counterparts. Results: SM older adults reported higher usage (36%) of mind-body therapies compared with heterosexual adults (22%), with lesbian women reporting the highest use (39.4%). Having a SM identity was associated with mind-body therapy use; SM older adults were 57% more likely to use a mind-body therapy. Conclusion: Mind-body therapies may be a useful tool for SM older adults to enhance their health and well-being. Future qualitative research is needed to investigate more deeply the reasons SM older adults use mind-body therapies. To advance the health and well-being of SM older adults, the authors also need intervention studies that explore the effectiveness of mind-body interventions and the possible need for tailoring these to the unique needs of this population.

Greater Social Engagement and Greater Gray Matter Microstructural Integrity in Brain Regions Relevant to Dementia

OBJECTIVE

Social engagement (SE) may protect against cognitive decline in older adults. We estimate associations of SE with gray matter (GM) microstructure in regions of interest (ROI) relevant to social cognition, among community-dwelling older adults.

METHOD

Cross-sectional analysis of 293 Health ABC study participants who underwent 3 Tesla magnetic resonance imaging with diffusion tensor and free from cognitive impairment was conducted. Linear regression models tested associations between SE index (marital status, not living alone, social activities, work, and volunteering) and mean diffusivity (MD) of GM ROIs, adjusted for age, race, gender, and education. Hearing and activities of daily living (ADL) difficulties were tested as confounders. Effect modification by gender was tested with interaction terms and stratification by gender.

RESULTS

Higher SE was significantly related to lower MD (greater GM microstructural integrity) (shown as standardized estimate [p-value]) in left middle frontal gyrus-orbital part: -.168 (.005), left caudate nucleus: -.141 (.02), left temporal pole-middle temporal gyrus: -.136 (.03), right middle frontal gyrus: -.160 (.006), right superior frontal gyrus-orbital part: -.187 (.002), and right middle frontal gyrus-orbital part: -.124 (.04), when adjusted for demographic attributes. Associations were robust to adjustments for hearing or ADL difficulty. There was significant effect modification by gender for some ROIs, with associations only for females.

DISCUSSION

SE is related to greater microstructural integrity of specific GM regions relevant to social cognition, that have described roles in dementia. SE may therefore be a useful preventive mechanism against loss of GM integrity in older adults.

Learning from Transmasculine Experiences with Health Care: Tangible Inlets for Reducing Health Disparities Through Patient-Provider Relationships

Purpose: We examined health care experiences of transmasculine young adults to clarify factors contributing to mistrust in the health care system and identify tangible and modifiable means to address health disparities through improved patient-provider interactions. Thematic analysis highlights patterns within historical relationships between medical models and transmasculine embodiment, and provides guidance for health care clinicians, researchers, and policy makers to deliver competent services for transgender and gender diverse (TGD) individuals. Methods: The study team used qualitative methodology guided by interpretive phenomenological analysis. Semistructured interviews with 12 participants who self-identified as transmasculine were conducted, transcribed, and coded thematically. Results: Participants were a community sample of 12 young adults 18-35 years of age (M=23, standard deviation=3.74), who self-identified as transmasculine. Three participants identified as a racial/ethnic minority. Participants were highly educated, with most completing at least some college. The superordinate thematic domain Perspectives on Health Care emerged, under which three subthemes were nested: (1) an essentialist, binary medical model is inaccurate and oppressive, (2) consequences of medicalizing gender (i.e., gender as a diagnosis), and (3) recommendations to improve health care. Conclusions: Qualitative analysis revealed specific ways in which the relationship between transmasculine individuals and current health care systems are fraught with difficulties, including the impact of stigma, gatekeeping, and inaccuracies, in current diagnostic criteria. Participants shared lived experiences and offered innovative ideas to improve health care delivery, such as challenging socialized biases, increased education, and immersion in TGD communities to advocate for change in research, practice, and policy.

A Community Choir Intervention to Promote Well-Being Among Diverse Older Adults: Results From the Community of Voices Trial

OBJECTIVES

To test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults.

METHOD

Twelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months.

RESULTS

The sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs.

DISCUSSION

Findings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects.

CLINICALTRIALS.GOV REGISTRATION

NCT01869179 registered January 9, 2013.

USE OF COMPLEMENTARY THERAPIES BY SEXUAL MINORITY OLDER ADULTS: FINDINGS FROM THE NATIONAL HEALTH INTERVIEW SURVEY

Sexual minority (lesbian, gay, bisexual; LGB) older adults age 50+ experience a higher prevalence of chronic disease and disability, as well as a poorer physical and mental health status. Many adults use complementary and integrative therapies, particularly mind-body therapies, as health-enhancing approaches and to support wellbeing. However, no study to date has examined the use of mind-body therapies among sexual minority older adults. We examined data from the 2017 National Health Interview Survey to determine the use of mind-body therapies by sexual minority older adults (aged 50+), as well as the influence of health and wellbeing characteristics on mind-body therapy use, compared with their non-LGB counterparts. Sexual minority older adults overall reported higher usage (36%) of mind-body therapies compared with their non-LGB counterparts (22%), with lesbians reporting the highest use (41%). Sexual minority identity was a significant predictor of mind-body therapy use, with LGB adults roughly two times more likely to use a mind-body therapy after controlling for chronic disease status and other wellbeing measures. Future research is needed to explore the reasons sexual minority older adults use complementary and integrative therapies, as well as potential development of mind-body interventions targeted toward this population to address stress and quality of life.

BUILDING H.O.U.S.E. (HEALTHY OUTCOMES USING A SUPPORTIVE ENVIRONMENT) FOR LGBTQ OLDER ADULTS

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults face unique challenges in finding affordable, inclusive, and supportive housing. These challenges may be due to discrimination, income disparities, and higher rates of health problems compared to cisgender heterosexual seniors. To our knowledge, this is the first longitudinal study of the health and wellbeing of older adults who move into LGBTQ-welcoming, affordable senior housing. Participants completed a brief baseline survey at the time of their housing lottery application. Questions focused on physical, psychological, and social health and current health service use. We calculated descriptive statistics on health status at baseline. 184 participants completed the baseline survey, mean age was 68 years (SD 5.2), and nearly 75% reported an annual income under $30,000. Almost half reported a diagnosis of hypertension, 40% depression, 27% anxiety, and 25% HIV/AIDS. Around 70% reported their health as good to excellent, 21% fair, and 9% poor or very poor. However, 58% reported their physical activities were at least somewhat limited by their physical health, 43% reported difficulties with balance or walking, and 32% reported memory problems. Nearly 3% had been admitted into the hospital and 10% had visited the emergency room in the past 30 days. In terms of social wellbeing, 63% felt isolated from others at least some of the time. In summary, LGBTQ older adults seeking affordable senior housing report relatively good health, although they also experience functional and social difficulties. New forms of housing that are explicitly LGBTQ-welcoming may help address these health challenges.