Responding to delusions and hallucinations - understanding the message

This guide assists you in understanding some of the potential causes of delusions and hallucinations, and how the person with dementia can be supported. The support aims to alleviate the person’s distress and minimise the impact on the person’s care.

If attempts to respond to the person are not effective, or the person becomes more distressed, it is not recommended to continue as this may lead to physical distress. Trying to listen rather than responding to the person can sometimes assist with preventing an adverse reaction. Allowing time out will assist with de-escalating the situation and ensure that the safety of the person with dementia and others involved is maintained.

Responding to delusions
What is a hallucination?
Responding to hallucinations
Useful resources

Responding to delusions

It is important to take delusions seriously and never dismiss them as a symptom of dementia. The person is experiencing real fear or anger and distress, whether the belief is true or not. The following offers examples of common delusions, and how to respond to them.

Theft

In this situation, the person believes that someone has stolen from them. Never assume that this is a delusion at first – the person may have a good reason to believe this. Do:

  • Take the person’s concerns seriously.
  • Ask questions that encourage the person to tell you more.
  • Listen carefully to the person’s answers to understand why the person believes that something has been stolen.
  • Change the topic of conversation to something that is comforting to the person, if the person’s level of distress is escalating.
  • Find out if some money in the person’s purse or wallet will help alleviate anxiety, if this is an ongoing concern.
  • Obtain more detail, report to a supervisor and be guided by the person as to their experience of the situation.

Spousal/Partner Paranoia

In this situation, the person has suspicious beliefs that their spouse or partner is having an affair. This is a common fear and can be difficult to manage, as the spouse/partner does not want to encourage the person’s delusion of an affair by asking more questions. Do:

  • Listen attentively and encourage the person to say what is on their mind.
  • Validate the emotions that are expressed.
  • Let the person know you are very sorry they feel this way, and try to gently change the subject.
  • Recognise that trying to reason or use logic – or bluntly disagreeing with the person – is unlikely to be helpful.
  • Avoid simplistically agreeing with the person or reacting sensationally to the belief, as this may open up a whole different set of problems.
  • Consider whether humour may help reduce the anxiety. This tends to be more effective in situations where humour is an integral part of the relationship, e.g., “Don’t be daft, I wouldn’t have the energy for all that nonsense!”
  • Try to reassure the person by using reminiscence to alleviate distress, e.g., “Remember our wedding day, how much we loved each other and what a beautiful honeymoon we had…”

Victimisation and paranoia

In this situation, the person believes that others are against them or intend to cause harm to them. For example, family members may be visiting frequently, and the person may feel that the intent of the visit isn’t honourable. Do:

  • Acknowledge and accept the person’s concern, as it is their experience.
  • Try and find out as much as possible and provide support, reassurance and redirection.
  • Try to find out the contributing factors to the belief.
  • Assess the person’s health, effects of medication and experience of pain. The person maybe feeling unwell and think someone is trying to harm them.
  • Find out if another resident is getting lost and entering the person’s bedroom frequently.

Living in the past

In this situation, the person is having difficulty orientating to time and place; for example, an 85-year-old woman may be looking for her toddler. A natural reaction is to attempt to persuade the person and to orient them back to the current day. This is largely ineffective and will only add to the distress and create mistrust. Do:

  • Notice the person’s emotions and validate the person’s feelings. If possible engage in positive conversation on the topic e.g., “You look very worried about him, how old is your little boy?”
  • Avoid contradicting the person. Telling the person they no longer live in that home, or no longer have young children, is likely to increase anxiety and distress.
  • Consider what need may underlie the person’s belief and how this need might be met.
  • Find out more about the person, so that if a redirection is used, it is individualised to the person.

What is a hallucination?

A hallucination is a sensory experience that occurs in the absence of actual sensory stimulation. Hallucinations in dementia are most commonly visual but can involve other senses like hearing and touch.

Responding to hallucinations

Visual hallucinations

Visual hallucinations occur when the person with dementia is seeing something although there are no cues for it in the outside world. Do:

  • Validate the person’s hallucination. By doing this you are not agreeing that the hallucination is real or denying its existence. Instead you are letting the person know that you understand what they are feeling and believing.
  • Investigate possible physical causes such as delirium, dehydration, urinary tract infection, chest or other infection or reactions to medication.
  • Check the person’s eye health and vision. Hallucinations may be related to some eye condition that can cause vision loss.
  • Change the environment, as this can assist to distract the person from a distressing image and focus the person’s attention on another topic or activity that they enjoy, e.g. a stroll in the garden.  

Vision and perception

People with dementia can experience a number of visuo-perceptual difficulties due to normal ageing, eye conditions, and sometimes from additional damage to the visual system caused by specific types of dementia. 

Vision difficulties can result in illusions, misperception, misidentifications and sometimes even hallucinations. They can cause the person with dementia to misinterpret their environment, which may cause the person difficulty in explaining what they have seen.

It’s important to ensure that the person with dementia has access to regular eye care and visual health. A visit to the optometrist will ensure that the prescription is correct and that there are no physical causes, e.g. cataracts. Do:

  • Minimise visuo-perceptual problems by ensuring good, even lighting.
  • Recognise that it is normal for all people to need more lighting to maximise their vision as they age.
  • Try to eliminate shadows and glare.
  • Minimise busy patterns on walls and flooring.
  • Cover up or remove or replace mirrors and shiny surfaces if they are problematic.

Misidentifications

In this case, a person with dementia has incorrectly identified an object or a person, for example, a man tries to use a black remote control as a shaver, or a woman is unable to distinguish between her son, husband, and brother. This may be caused by damage to specific locations of the visual cortex.

Misperception and illusions

These can be described as inaccurate or distorted visual information. Misperception can be influenced by previous experience and expectation. Examples include walking down a long, dark corridor with benches along the wall resulting in the person with dementia thinking it was a train station; or a man approaching a lift that had three large mirrors in it, and mistaking his reflection as a crowd of people who would not move to allow him in.

In responding, do:

  • Acknowledge what the person is seeing and reassure the person you are there to help them. 
  • Avoid correcting the person. Telling them what they say they are seeing is incorrect is likely to increase anxiety and distress.

Useful resources

The DBMAS Behaviour Management: A Guide to Good Practice is a good resource for managing behavioural and psychological symptoms of dementia.

Hallucinations and delusions: how to cope with hallucinations and paranoid delusions explores how to prevent and cope with dementia-related symptoms.

Dementia Australia offers an overview of Hallucinations and false ideas.
This five-minute video runs through a scenario involving hallucinations and delusions.

This resource material is informed by literature and associate practice evidence. This guidance should be applied within your organisations policies and procedures.
 
©HammondCare Dementia Centre November 2018 (next review date November 2020)