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Psychosis (Hallucinations and Delusions)

Psychosis refers to an affective condition in which a patient has lost touch with ­reality and has hallucinations, delusions, or both. The presence of psychosis in the initial months or year of a dementia suggests a non-Alzheimer’s dementia or aggravating factor (such as medication) in the context of Alzheimer’s disease.

Hallucinations

A hallucination is an abnormal sensory perception of a stimulus that isn’t really there. The most common types of hallucinations in dementia are visual (seeing things), auditory (hearing something), or tactile (sensation of feeling something). In dementia, visual hallucinations are the most common, but auditory hallucinations may also occur. Tactile hallucinations suggest a different diagnosis than dementia. Hallucinations are a diagnostic criterion in Dementia with Lewy bodies and occur in approximately 10 % of patients with Alzheimer’s dementia [1].

Delusions

A delusion is a fixed false belief that is resistant to reason or confrontation with facts. The take-home points from this formal definition are the words “fixed” and “false.” Delusions may involve paranoia (in which a patient mistakenly believes that others are trying to inflict harm in some way). Delusions are estimated to occur in approximately 22 % of Alzheimer’s dementia patients [1, 2].

Delusions of Theft

One of the most common examples that we encounter in our clinical practice is a dementia patient who experiences a delusion of theft. The patient mistakenly thinks that someone is entering the patient’s residence and taking things or moving them around. Often what is actually occurring is that the patient with dementia is losing or hiding belongings from himself or herself.

When Mom asserts that there is someone coming into the home, the family often assumes that Mom is hallucinating. On further questioning, we often determine that Mom just thinks that there is someone in the house and is therefore having a delusion rather than a hallucination. She may cite evidence of the intruder, naming missing items or items being relocated within the home.

Let us walk through another common example. Dad has Alzheimer’s disease, and one of his sons takes over managing Dad’s financial affairs. The son oversees bank statements, pays bills, manages Dad’s investments, etc. Dad becomes convinced that the son is stealing from him. The son provides Dad full access to the accounts to show him everything is being handled appropriately. Dad is unmoved by the information. Other family members go over bank statements with Dad to reassure him that all of his finances are in order. Dad continues to assert that son is stealing despite this evidence to the contrary.

Many families understandably struggle in these situations. Even when children are educated and insightful about the situation, it hurts to have your father accuse you of stealing. It may cause a rift in the parent–child relationship which is even more wounding. So what do you do? First realize the idea that son is stealing is fixed and false. Therefore, you can stop arguing with Dad. Deep down we often feel that we can convince Dad that he is wrong. And we can not. You can present document after document to prove your case. You can plead, argue, and threaten if you want. However, it typically does not bring resolution. As one of the children, when Dad tries to engage you in conversation about the stealing, provide one reassuring statement and change the subject. If you cannot change the course of the conversation, end the phone conversation or walk away. Of course you can consider other reasonable options, such as paying an accountant to manage Dad’s affairs, as long as you realize the accusations may transfer to the new person.

But, if your loved one is experiencing psychosis, don’t despair. As the above example shows, certain methods may be employed successfully. We offer a number of tips in the following sections to help you steer clear of what doesn’t work and identify what will.

Addressing Psychosis

Here are a few techniques to keep in mind (and at hand) that you can draw on in a pinch.

First, provide comfort and reassurance. If your husband has a delusion that strangers are in the bedroom, remind him that you’re with him and he’s safe. You might turn on lights if it is dark or look around a room (including opening closet doors) with him so that he can see that any supposed intruders are no longer there (“Oh, look they’re gone!”) and you might make a show of checking any external door locks.

In addition to specific hallucinations and delusions, patients with dementia may have generalized paranoia. Alzheimer’s patients may hide their valuables for fear they will be stolen. The memory deficits of this disease then impair the patient from remembering they hid the valuable. So this reinforces the paranoia as the object is actually missing. Families often file complaints with their loved one’s living facility about missing items only to later discover them in a hiding place in their loved one’s apartment. So, when Mom states her pearl earrings have been stolen, take a logical approach. Ideally you have an inventory of the belongings she took with her when she moved. First, verify if the earrings are listed on the inventory. The inventory alone saves a round of questioning about the missing item. Patients may get irritable if they feel family doubts them or questions their recall. If the earrings are on the inventory, carefully look through the entire apartment, not just where Mom keeps her jewelry. You might do so discreetly or together with Mom. If you have tried all of these measures and the earring still cannot be found, notify the administration.

Common sense rule:Support and reassure a patient with psychosis.

Think of hallucinations and delusions in the context of the brain sending aberrant signals. Unlike how hallucinations are portrayed in the movies, there is no halo around or hazy effect to the image. The brain signals that there is someone sitting across from Dad just as if there is one. That is why you cannot correct the misperception with words and it works best to avoid explanations, especially lengthy ones.

Instead of providing your thoughts on the matter (“Mom, I think you misplaced your earrings. I do not feel the staff is stealing.”) opt for a strong declarative statement in attempts to end the discussion. You could try, “Mom, don’t worry. I’m going to handle this.” You don’t have to provide specifics, such as that you’re going to talk with the administrator, even if you are. Stay general but assertive. We recommend not engaging in lengthy conversations about the alleged theft. Paranoia is often driven by fear. We want Mom to feel reassured and know that you are looking out for her.

Don’t correct, contradict, or otherwise confront or argue with a person who is having a hallucination or delusion. As a matter of fact, this is almost always a sound rule to follow for patients with dementia. All of these may just upset your loved one (and you will probably find it distressing as well).

Common sense rule:Avoid explanations or confrontation.

If you are going to address the psychosis head on, try a more medical interpretation to allay a patient’s anxiety. You might gently remind Mom: “Remember, Dr. Smith said your mind may send some mixed-up signals sometimes.” Then find an activity to engage the mind, preferably in another room. Distraction works well for psychosis and other behavioral problems. You can change the topic of conversation, activity, or even the venue. A snack may be just the thing. Changing the environment may help the brain let go of the image. You might take a patient to another room or even out of the house. This often works well for patients who are convinced that they aren’t at home when in fact they are. After taking Mom to another room or place, you can bring her back and show her a couple of her favorite things (such as beloved photo, painting, or armchair), reassuring her that she is indeed home.

Common sense rule:Distraction works wonders.

Humor helps defuse potentially explosive situations. When you sense the conversation turning toward the delusional idea, insert a funny story about one of the grandkids. You might memorize some jokes, have a joke book handy in the house, or carry one with you. Laughter really is the best medicine.

Common sense rule:Humor defuses tension.

When Medication is Needed for Psychosis

Unfortunately, sometimes behavioral interventions are not enough for patients with psychosis. In these cases, the paranoia interferes with quality of life such that further action is needed. Maybe there is police involvement due to repeated calls from a patient reporting theft. Or maybe the paranoia leads to agitation that compromises the patient’s ability to reside in his current level of care. Or maybe the patient is so burdened by her concerns that she will not leave her apartment for meals because would be leaving valuables unattended. There are no FDA-approved medications to treat dementia-related psychosis, but antipsychotic medications, which have FDA indications for other forms of psychosis, such as bipolar disorder and schizophrenia, may be used “off-label” if a patient is suffering. Be advised that all antipsychotics carry a FDA boxed warning regarding their use in dementia. The warning summarizes evidence that there is a 1.6- to 1.7-fold increased risk of death for dementia patients who take antipsychotic medication compared to those who do not. The studies that led to the FDA warning found the mechanism of death was mostly cardiac or pneumonia in origin. The antipsychotics also carry metabolic risks, such as increased blood sugar and cholesterol, as well as orthostatic risks, such as lowering blood pressure on standing. Sedation is also a risk for the majority of antipsychotics. We recommend a careful review, discussion, and consideration of the risks and benefits of such medication for any individual with dementia.

Summary

Patients with dementia may experience psychosis, which can include hallucinations or delusions. Hallucinations involve an abnormal sensory perception, whereas delusions portend fixed, false ideas. Minimizing any identifiable triggers may help prevent psychosis. Caregivers should offer comfort and safety for the person experiencing psychosis while sidestepping any arguments, conflict, or confrontation through the use of distraction and other behavioral and environmental measures. Antipsychotic medication may be prescribed for patients with dementia, but have known and serious risks which should be carefully considered.

Common Sense Rules

  • Identify and avoid behavioral triggers.

  • Avoid explanations or confrontation.

  • Find the right balance of stimulation.

  • Maintain a daily routine of structured activities.

  • Support and reassure a patient with psychosis.

  • Distraction works wonders.

  • Humor defuses tension.