Transgender older adults face a unique and under-researched set of health risks, particularly in relation to cognitive decline. This mixed-methods study explores how lifelong discrimination contributes to cognitive vulnerability among elderly transgender individuals in India. Quantitative data were collected through surveys with 137 participants aged 45 and above, while qualitative insights were drawn from 35 semi-structured interviews. Results revealed that the mean cognitive decline score (M = 5.93) was significantly higher than the general population benchmark (t(135) = 5.39, p < 0.001), with qualitative narratives expressing fear of gender reversal due to memory loss. Notably, over 69 % of respondents lacked confidence in healthcare providers' knowledge of transgender health needs, and 60 % reported frequent or constant social isolation. The findings were interpreted using Minority Stress Theory, highlighting the compounded impact of lifelong stigma, medical neglect, and aging. This study underscores the urgent need for trans-inclusive memory care, provider training, and policy-level reforms in eldercare services. © 2025 Elsevier B.V., All rights reserved.