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DISCLAIMER ...
There is no hard and fast answer to addressing a problem behaviour.
The following information is provided as a tool to help the Caregiver find the solution that works for situation they are faced with.

Problem Behaviours - Hallucinations / Paranoia

| Possible Causes | Coping Strategies | Other Considerations | Additional Information

As Alzheimer's disease enters its later stages, patients will often begin to have periodic trouble separating the real from the unreal. Learning about hallucinations and delusions can help you cope with the situation more effectively.

It is important that Alzheimer's caregivers understand the difference between a hallucination and a delusion because each of these symptoms can affect your loved one in different ways:

Hallucinations - These involve false perceptions, and are also caused by changes in the brain due to Alzheimer's. Patients can literally “sense” — see, hear, smell, taste, or feel — something that isn't there. They might see and talk with old friends who aren't there, or watch ships floating through the sky outside the window, or smell foods they enjoyed as a child.

Delusions - Delusions are false beliefs caused by the deterioration of cognitive processes in the brain of the Alzheimer's patient, and are often influenced by misunderstandings or misinterpretations. Patients might think they are being followed, or might accuse a family member of stealing from them or plotting against them.

These hallucinations or delusions can be quite frightening and anxiety-inducing to the person.
It's not uncommon, for example, for an Alzheimer's patient to suddenly believe that someone or something is out to harm them, or that a close family member has turned on them. Knowing what’s behind hallucinations and delusions, and what to do when they come up, can help you to approach the situation in a rational way so you can make the situation easier on everyone involved

Possible Causes

Physiological or Medical Causes

  • Sensory deficits, especially diminished hearing and poor vision, also diminished taste
  • Medications - particularly hormones in combination with anti-depressants
  • Brain damage (due to Alzheimer's disease)
  • Physical trauma from a blow during a fall or accident
  • Malnutrition, including low fluid intake
  • Psychiatric illness concurrent with Alzheimer's (Alzheimer's is NOT a psychiatric illness)
  • Memory loss due to brain changes and damage
  • Physical illness …fever, pain, fecal impaction, anemia, respiratory disease

Environmental Causes

  • Unfamiliar environment
  • Unrecognized environment
  • Not recognising caregiver
  • Unfamiliar caregiver
  • Disruption to routine
  • Removal of items from the person, such as money or jewellery

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Coping Strategies

  • Have vision or glasses examined... Rapid visual deterioration is unusual, but so are regular eye exams... Visual impairment easily leads to misinterpretation of the environment.
  • Have hearing tested or hearing aid regularly serviced... Diminished hearing also leads to "hearing noises" that are unintelligible, which in turn lead to "auditory hallucinations."
  • Seek a medical evaluation to assess for illness, infection, chronic pain or bowel impaction.
  • Seek a psychiatrist's evaluation of paranoia, delusions, hallucinations, false ideas, or suspiciousness to determine if medication may be helpful.
  • Seek a physician's review of medications, including any over-the-counter medications that are being taken.
    • Some medications may be helpful in reducing anxiety. Common anti-anxiety medications such as Valium®, Antivan® and Klonapin® often worsen dementia symptoms.
    • Low dose major tranquilizers, such as Haldol®, are usually more useful (although they occasionally worsen symptoms as well).
    • Watch the actual ingestion of medications to be sure the person is swallowing them.
    • If the person has trouble swallowing pills, ask if there is a liquid form of the medication available.
  • Visually inspect the head and face for bruises or scrapes from unwitnessed falls.
    • If these are present, seek medical evaluation.
    • This is especially important if there is also a sudden change in the person's level of alertness.
  • Use helping strategies to intervene with eating and feeding problems. (see "Eating" for further suggestions.)
  • Change environment as little as possible.
  • When it is necessary to change the environment:
    • Include familiar objects from the old environment
    • Wherever possible, have a trusted caregiver explain the new environment
  • Give the person a regular and recurring simple task to do in the environment (making their own bed, watering a plant, cleaning tables, etc).
  • Explain potential or actual misinterpretation: "that loud noise is an airplane flying overhead"
  • Carefully choose your arguments with the suspicious person.
  • Arguing or trying to reason with a person often makes the situation worse and can result in increased agitation or anger, creating more stress for everyone.
  • Do not directly disagree with a false idea by arguing.
  • State what you know to be true, and then attempt distraction, e.g., "Let's go for a walk."
  • Respond to general feelings of loss, that are within specific statements of loss.
  • Specific statements may be "My father is at work", when their father is dead.
    • The memory of the person may be stronger than the memory of his death.
    • Instead of telling the person their father is dead, try saying, "you must miss your father," or "it sounds like you loved your father very much," or "tell me about your father."
  • When a person is upset about something that may be missing, try to discuss his/her feelings about the lost object.
    For example, Mr Sherba's dog died six months ago and he misses his dog desperately. In a recent conversation with his son, Mr Sherba angrily accused him of hiding the dog. In response to the accusation his son replied, "You really miss the dog and I do too. She was such great company. Do you remember how she used to play with the neighbours dog? Let's go next door and see if the neighbours dog is in the backyard."
  • Investigate suspicions that may be founded on fact... The person may actually be a victim of robbery or harassment.
  • Explain to individuals who have frequent contact with suspicious dementia victim that you do not suspect them and that the accusations result from the confused person's inability to assess reality accurately.
  • Use familiar distractions such as: music, exercise, card playing, conversations with friends, reviewing photo albums, rolling coins, playing with pets, drawing and sketching.
  • The purpose of the distraction is not to create a great product but to distract.
  • Establish or reinforce a daily routine or pieces of a daily routine, such as meal rituals or bedtime rituals.
  • Routines help give structure and a sense of the familiar to the individual who lives in an unfamiliar world.
  • Even a simple daily routine can help increase a sense of security.
  • Use physical touch as reassurance, if the person is willing to accept physical touch - don't force it upon them.
  • Saying "I know your upset," or "Would it help if I held your hand?" may reassure the person.
  • Non-verbal reassurance such as physical touch or tone of voice often "gets through" when verbal communications don't.
  • Encourage structured or supervised "people contact" with friends and family who are aware and accepting of confused individuals.

Try these approaches for misplaced objects and suspiciousness:

  • Remind the individual where valuables are stored for safekeeping.
  • Provide small amounts of money to individuals accustomed to having money on their person.
  • Look for lost articles or assist in looking.
  • Do not scold for losing items or hiding things
  • If feasible, keep a spare set of items that are frequently missed such as purse, keys or glasses.
  • Learn where the individual's favorite "hiding places" are, and let other caregivers know.
  • Increase lighting in the environment ... higher wattage, nightlights... Shadows can lead to visual hallucination

For tasks or activities, try to:

  • Allow adequate time for person to respond to directions, request, or to perform activity... Due to physical changes in the brain, more time is needed to absorb instructions.
  • Limit choices such as with food, activities or clothing... Decision-making may be overwhelming to the person and result in an angry response.
  • Give clearly stated directions for each step... Complete one step at a time.
    • The person no longer has the ability to think of several things at once and may be overwhelmed in trying to keep track of multiple events, statements, questions or directions.
  • Offer activities and events that the person is capable of doing.

In long term care settings:

  • Try to maintain consistent staffing... When possible have familiar staff person be responsible for person with dementia.
  • Try to involve families or volunteers in one-to-one activities, if large group activities are upsetting to person.
  • Identify stressful times of day for person and try to schedule baths, dressing, or other difficult activities at other times.
    • Discuss successful and unsuccessful approaches with other staff.
    • Be aware that shift changes are often stressful times and provoke anxiety because of increased noise and activity level

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Other Considerations

  • Everyone is normally suspicious, some people more than others... The confused individual awakens each day in unfamiliar surroundings, having forgotten his/her environment and trusted people in it... It is understandable that they are suspicious.
  • It may be helpful to keep a diary or log in order to pinpoint whether there are particular times of the day, places, or people that precede hallucinations or suspiciousness. .. If these can be identified, it may be possible to alter the routine and avoid such behaviours, or to anticipate problems and be ready with distractions.
  • Hallucinations and false ideas may be harmless and these are best ignored or accepted... If they do not upset the person who is experiencing them, there may be no reason for the caregiver to intervene.
  • It is important for caregivers not to take accusations personally... Remember that personality changes are a result of the illness.
  • It is also important for caregivers to recognise that the person can't control these behaviours.
  • Actual damage to the brain occurs in dementia which eclipses inhibition.

Additional Information

Gwyther, Lisa. Care of the Alzheimer's Patients: A Manual for Nursing Home Staff. American Health Care Association and the Alzheimer's Association (ADRDA), 1985.

Mace, Nancy and Rabins, Peter. The 36-Hour Day. Baltimore: The Johns Hopkins University Press, 1981.

Powell, Leonore and Courtice, Katie. Alzheimer's Disease: A Guide for Families. Massachusetts: Addison-Wesley Publishing Company, 1983.

Safford, Florence. Caring for the Mentally Impaired Elderly: A Family Guide. New York: Henry Holt and Company, 1986.

Wolanin, Mary and Phillips, Linda. Confusion: Prevention and Care. St Louis: C.V. Mosby Company, 1981.

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