A 76-year-old female transgender person was diagnosed with Alzheimer's dementia in 2014 with MOCA (MOntreal Cognitive Assessment) score of 17/30. She was treated with donepezil 10mg OD and prescribed mirtazapine 15mg ON to treat insomnia and low mood. She underwent male to female gender reassignment surgery, including bilateral breast surgery completed in 1960s, and hormonal treatment with estradiol. She considered her sexual orientation to be towards the same sex, and she was in a long-term relationship with a female partner. Her medical history included migraine and she was on propranolol 80mg OD. There was no other significant psychiatric history. She resided in her own flat and her partner lived in a separate flat in the same block. The couple had two of three surviving adopted daughters, both in their forties. The patient's primary carer was her partner and there was no formal care input. In 2016, her MOCA score dropped to 11/30 and she had impaired hygiene and nutrition. In 2018, she started wandering and bringing men to her flat and engaging with them in sexual activities leading to a high risk of vulnerability to abuse culminating in Mental Health Act assessment and admission to a dementia unit. MOCA was not performed due to receptive and expressive dysphasia. In the unit, she presented with insomnia, agitation, dysphasia, having sexually inappropriate conversations with staff about being interested in men, which was a continuation of new behaviour that was identified in the community, as well as making innuendos to female members of staff while talking about herself as a ‘man’. She presented with toileting behaviour that would identify her as male gender, for example standing to urinate as if using a urinal, interpreted as reversal towards biological gender identification. Her partner felt devastated by behaviours exhibited by the patient, which could be identified as male-gender based behaviour aligned with biological gender by birth.
