Transgender Adults More Likely to Experience Subjective Cognitive Decline, Depression

DENVER, JULY 28, 2021 — Transgender and gender nonbinary adults in the U.S. are more likely to report worsening memory and thinking, functional limitations and depression compared to cisgender (non-transgender) adults, according to two studies reported at the Alzheimer’s Association International Conference^® (AAIC^®) 2021 in Denver and virtually.

Little is known about Alzheimer's disease, dementia and cognitive impairment among transgender adults. However, it is known that transgender adults experience a greater number of health disparities considered risk factors for dementia — including higher cardiovascular disease, depression, diabetes, tobacco/alcohol use and obesity — and the social inequities experienced by transgender adults are also linked to an increased risk of cognitive impairment.

One of the first clinical manifestations of Alzheimer’s disease may be subjective cognitive decline (SCD), a self-reported experience of confusion or memory loss that is happening more often or is getting worse.

• Transgender adults — individuals who identify with a gender different than the one assigned to them at birth — were nearly twice as likely to report SCD and more than twice as likely to report SCD-related functional limitations, such as reduced ability to work, volunteer or be social.
• Prevalence of depression was significantly higher for transgender and gender nonbinary adults (individuals who identify outside the male/female binary) (37%) compared to cisgender adults (19.2%). Additionally, reports of cognitive disability, a surrogate for SCD, were significantly higher in transgender and nonbinary adults (24.7%) compared to cisgender adults (10.5%).

“We know far too little about Alzheimer’s, dementia and cognitive well-being among transgender and gender nonbinary individuals,” said Carl V. Hill, Ph.D., MPH, Alzheimer’s Association chief diversity, equity and inclusion officer. “As we learn more about dementia within this population, there is a great need for health care that is culturally competent and delivered with humility to address the needs of aging transgender individuals and their loved ones.”

The first dementia prevalence data for U.S. lesbian, gay and bisexual individuals were reported at AAIC 2018, followed by the first data report suggesting higher rates of SCD among lesbian, gay, bisexual and/or transgender Americans at AAIC 2019. Also that year, the Alzheimer’s Association partnered with SAGE (Advocacy & Services for LGBT Elders) to develop an issues brief and infographic that offers recommendations for working with LGBT people living with Alzheimer’s or other dementias, as well as supporting LGBT-identified caregivers for people living with dementia. Among those recommendations is using gender-affirming language. The Association also maintains a list of resources for the LGBT community and caregivers on its website.

Transgender Adults Report More Subjective Cognitive Decline Than Cisgender Adults
Using data from the 2015-2019 Behavioral Risk Factor Surveillance System (BRFSS), a large annual health behavior survey led by the Centers for Disease Control and Prevention (CDC), Ethan Cicero, Ph.D., RN, Assistant Professor at Emory University’s Nell Hodgson Woodruff School of Nursing, and colleagues examined data on SCD and associated functional limitations — including giving up day-to-day activities or interferences with ability to work, volunteer or engage in social activities — among transgender and cisgender adults

Approximately 17% of transgender adults (1 in 6) reported SCD, which is significantly higher than the 10.6% rate for cisgender adults (roughly 1 in 10). Among those reporting SCD, transgender adults were 2.3 times more likely to report associated social and self-care limitations when compared to cisgender adults. Among those reporting SCD, transgender adults were about three years younger and more likely to be a racial/ethnic minority, to be uninsured, and to have depression.

Barriers to health care were a concern among transgender adults — 1 in 3 transgender adults who experienced worsening memory problems and 1 in 2 transgender adults with related social and self-care limitations were unable to see a doctor because of cost.

“We are not certain what may be causing the elevated subjective cognitive decline rates among transgender adults. We postulate that it may be in part due to anti-transgender stigma and prejudice that expose transgender people to high rates of mistreatment and discrimination where they live, work, learn, seek health care and age,” Cicero said. “More research is needed to identify and target preventive intervention strategies, develop culturally relevant screenings, and shape policies to improve the health and well-being of the transgender population.”

Depression, Cognitive Disability Higher Among Transgender and Gender Nonbinary Adults
Using data from the 2019 BRFSS, Nickolas H. Lambrou, Ph.D., assistant scientist, Gleason Lab at the Division of Geriatrics and Gerontology at the University of Wisconsin School of Medicine & Public Health, and colleagues examined associations between health conditions, cognitive disability and gender identity. Of respondents providing a gender identity (n=231,414), 955 identified as transgender or gender nonbinary (TNB).

The researchers found prevalence of depression was significantly higher for transgender and nonbinary adults (37%) compared to cisgender adults (19.2%). Additionally, reports of cognitive disability were significantly higher in TNB respondents (24.7%) compared to cisgender respondents (10.5%). Nonbinary respondents reported the highest proportion of depression (49.6%) and cognitive disability (30.5%) compared to all other gender groups. The analysis also suggested that men, whether transgender or cisgender, were more likely to report cognitive disability associated with depression compared to other groups. However, it is important to note that cisgender men also reported the lowest proportions of depression (14%) and cognitive disability (9.4%) compared to all other gender identity groups.

“This research demonstrates that the cognitive health of transgender or gender nonbinary adults is different than cisgender adults, and that there are health differences within the TNB population. Notably, TNB respondents reported depression and cognitive disability at more than twice the rate of cisgender adults,” Lambrou said.

“These rates are concerning because cognitive disability may be a risk factor or early indicator of Alzheimer’s or other dementia. Further research is needed; it is critical that researchers include measures to identify TNB participants so we have an accurate representation of their health and health behaviors,” Lambrou added.

About the Alzheimer's Association International Conference^® (AAIC^®)
The Alzheimer’s Association International Conference (AAIC) is the world’s largest gathering of researchers from around the world focused on Alzheimer’s and other dementias. As a part of the Alzheimer’s Association’s research program, AAIC serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community.
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About the Alzheimer's Association^®
The Alzheimer's Association leads the way to end Alzheimer's and all other dementia — by accelerating global research, driving risk reduction and early detection, and maximizing quality care and support. Our vision is a world without Alzheimer's and all other dementia^®. For more information, visit alz.org or call the 24/7 Helpline at 800.272.3900.

• Ethan Cicero, Ph.D., RN, et al. Transgender Adults Report Greater Cognitive and Related Functional Challenges: Findings from the 2015-2019 Behavioral Risk Factor Surveillance System.
• Nickolas H. Lambrou, Ph.D., et al. Prevalence of modifiable risk factors for Alzheimer’s disease and related dementias, and association with cognitive disability among transgender and gender non-binary adults in the U.S.; BRFSS 2019.

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