Delusions and Paranoia in Alzheimer’s: Tips for Caregivers

Hallucinations, delusions, and paranoia are common in individuals who have Alzheimer’s or other forms of dementia, including Lewy Body Dementia and Parkinson’s. Hallucinations involve seeing or hearing things that are not there. In dementia, most hallucinations are visual, and not all hallucinations are unpleasant.

Delusions as “false beliefs that the person thinks are real,” according to the NIH. Paranoia is the most common type of delusion among patients with dementia, explains Daniel Heiser, PsyD, Senior Vice President, Behavioral Health at GuideStar Eldercare, and it can feel very distressing.

Understanding delusions, paranoia

“Paranoia is a type of delusion in which a person may believe—without a good reason—that others are mean, lying, unfair, or ‘out to get me,’” explains the NIH. A person experiencing a delusion may feel suspicious, jealous, or fearful, they add.

In dementia, the experience of seeing or hearing things that have no basis in reality results from neuropathological changes in the brain. Memory loss plays a role in paranoia, says the NIH. For example, a nurse or aide can seem like a stranger and the unfamiliarity can trigger feelings of fear. Or a patient can misplace an object and then believe someone is stealing things. “The person may blame or accuse others because no other explanation seems to make sense,” suggests the NIH.

Experts at the UCSF Memory & Aging Center point out, “Strong emotional memories from the person’s past may re-manifest as delusions and hallucinations in dementia. The person may have trouble separating past experiences from current reality and may re-live these events to a certain extent.”

How to respond

For caregiving staff, responding to the feelings and behaviors that arise can be challenging. Here are some tips for responding when a patient is experiencing hallucination, delusions, or paranoia.

• Stay calm and be patient.
• Remind yourself that dementia is a brain disease manifesting symptoms, and what you may see is not intentional behavior.
• Avoid arguing with patients about what they see, hear, or feel. For example, in response to a visual hallucination, you can say matter-of-factly, “Oh, I didn’t see that” and move on.
• Acknowledge a person’s feelings. Use empathy in your responses, and then distract the person by moving to another room or focusing on a photo or keepsake. An example from UCSF: “I’m so sorry, that’s a scary feeling. Let’s take a deep breath. I don’t hear anything. Come with me, let’s make sure everything is okay.”
• Offer comfort in a respectful way if the patient is feeling afraid.
• Use gentle touching, such as holding a hand, hugging, or rubbing a person’s back.
• Let a patient know he or she is safe.
• Observe the patient’s environment for any noises, shadows, or objects that could be triggering fear.

Consult with the healthcare team

It’s important to maintain accurate documentation and communicate with other members of the healthcare team about neuropsychiatric and behavioral issues so that an accurate diagnosis can be established. Experienced psychologists and social workers on your dementia care team can help evaluate and interpret troubling behaviors.

Sometimes, short-term medications are valuable for reducing a patient’s distress, but “non-drug” interventions generally should come first, advises the Alzheimer’s Association. Comments UCSF, “Some behaviors cannot be ‘fixed’ using medicine...Some medicines can also cause negative side effects and actually make things worse.” The Antipsychotic Stewardship Program at GuideStar Eldercare uses a holistic approach to diagnosis and treatment, including polypharmacy review and gradual dose reduction.

As compared with a psychiatric illness, the neuropsychiatric basis of dementia symptoms is unique; this is why ongoing antipsychotic medication regimens are often not warranted. (Learn more in the blog, Reducing Antipsychotic Use in Nursing Homes: A Paradigm Shift.) Rather than simply treating a symptom, it is important to understand what is causing the behaviors; diagnosis counts, explains Anita Reid, MSN, APN, FNP-BC, GNP-BC, Senior Vice President, Nurse Practitioner Services.

As you care for patients who are experiencing paranoia or other breaks with reality, a keen focus on understanding the patient can go a long way in advancing dignity and quality of life.