Hallucinations in people with dementia

People with dementia can be affected by changes in the brain that lead to unfamiliar or frightening behavior. The symptoms that caregivers should know

The mind often plays tricks on people with dementia as brain cells degenerate.

Their brains often distort their senses to make them think they are seeing, hearing, and feeling, smelling or experiencing something that isn’t really there.

Such internal “miswiring” can manifest in different ways.

With illusions, an object is physically there, but dementia patients view it as something else. They might see a person in the corner instead of a coat tree, for example.

No object is present during hallucinations, but people’s brains tell them they are seeing children in the living room, hearing voices or feeling that there are strings in their mouths, to name a few common experiences.

Delusions, meanwhile, are fixed false beliefs or ideas that cannot be reasoned with. Capgras syndrome, in which the person with dementia thinks someone close to him or her is an imposter, is one such type of delusion. Another common delusion is blaming someone for stealing a misplaced item.

Visual hallucinations are one of the hallmark symptoms in lewy body dementia (LBD) and often occur early in the illness. In other dementias, delusions are more common than hallucinations, which occur well into the disease cycle, if at all, and are less often visual.

Fluctuating good days and bad days are another hallmark of LBD. On a good day, thinking is clear, and these illusions, hallucinations and delusions may not occur; on a bad day, they may be intense.

As LBD progresses, these types of symptoms may first intensify, then later burn out. 

In dementia, symptoms always change, so what a person experiences this month may not be happening the next month, though such distressing symptoms seem to last an eternity for the caregiver.

 “Happy” or benign hallucinations and delusions do not need medical treatment but rather the caregiver’s understanding and acceptance that this is a symptom of the illness.   

Understand that these experiences are a part of LBD — and they happen in most dementias. Many caregivers nonetheless are ashamed of the reactions in their loved ones.

Don’t be: Changes in the brain are creating this distorted reality.

Health professionals who are experienced in dementia care can suggest physical changes — removing the coat tree or other offending object, covering mirrors, improving lighting or using mouth-moistening solutions — that could ease symptoms.

Seek help if your loved one is distressed by illusions, hallucinations or delusions — or is at risk of hurting himself or others (with behaviors such as running away from hallucinations, leaving the house or fighting the episodes).

Describe the symptoms to your loved one’s physician at each visit. Such reporting will be helpful in tracking how often the delusion occurs. You don’t have to name it a hallucination or delusion; let the physician determine that.

Tell the physician if there is a marked change in the frequency or intensity of your loved one’s hallucinations. This may be the only clue that he or she is facing a medical problem such as a bladder infection, pneumonia, pain or constipation. 

If these approaches don’t help enough and the person is frightened and distressed by these distortions to reality, medication may improve the quality of life by reducing the intensity and frequency of hallucinations and delusions.

Hallucinations in people with dementia

A hallucination is an experience of something that is not really there. They can occur for all the senses, but visual hallucinations are the most common type experienced by people with dementia.

What are the different types of hallucinations?

Visual hallucinations can be as simple as seeing flashing lights. They can also be complex, such as seeing animals, people or strange situations. 

Less often in people with dementia, hallucinations can involve hearing, smelling, tasting or feeling things that do not really exist.

Hallucinations and different types of dementia

People with dementia are often thought to be hallucinating when in fact they are making mistake about what they have seen.

In some specific forms of dementia, hallucinations are more common. These include dementia with Lewy bodies and Parkinson’s disease dementia. People with Alzheimer’s disease can also experience hallucinations.

Hallucinations in people with dementia with Lewy bodies usually take the form of brightly colored people or animals. They often last for several minutes and can occur on a daily basis.

Some people with dementia with Lewy bodies can also experience hallucinations in other senses – for example, hearing things that aren’t there (auditory hallucinations) or smelling things that aren’t there (olfactory hallucinations).

People with other types of dementia may also experience these types of hallucinations, as well as tactile hallucinations (sensing things that aren’t there).

Tips for support during different types of hallucinations

If you suspect that a person is hallucinating, try to calmly explain what is happening. If they cannot retain this information, repeat it when they are more relaxed. If this is still not possible, don’t argue with them – it will not help.

Trying to convince someone that they are mistaken can lead to more distress for both you and them. Stay with the person and try to reassure them. Explain that even though you can’t sense what they do, you want to know what they are experiencing. Listen carefully to what they describe. There may be some language difficulties that may explain what the person is reporting. For example, referring to green cushions as ‘cabbages’.

Hallucinations may be limited to a particular setting. Gently leading someone away from where they are having the hallucinations can help make the hallucinations disappear.

Visual hallucinations

It may help to distract the person, and see if this stops the hallucinations. For visual hallucinations, consider making changes to the environment, such as improving lighting levels and reducing visual clutter. In addition, make sure that the person has regular eye checks, wears the correct glasses (if needed) and that they are clean.

Auditory hallucinations- auto-phony 

For auditory hallucinations, arrange to have their hearing checked. If the person wears a hearing aid, check that it is working properly and encourage them to wear it. People are less likely to hear voices that are not there when they are talking to someone real, so having company around may help.

When a person with Alzheimer’s or other dementia hallucinates, he or she may see, hear, smell, taste or feel something that isn’t there. Some hallucinations may be frightening, while others may involve ordinary visions of people, situations or objects from the past.

Understanding hallucinations

Hallucinations are false perceptions of objects or events involving the senses. These false perceptions are caused by changes in the brain due to Alzheimer’s, usually in the later stages of the disease. The person may see the face of a former friend in a curtain or may see insects crawling on his or her hand. In other cases, a person may hear someone talking and may even engage in conversation with the imagined person.

Alzheimer’s and other dementias are not the only cause of hallucinations. Other causes include:

  • Schizophrenia
  • Physical problems, such as kidney or bladder infections, dehydration, intense pain, or alcohol or drug abuse
  • Eyesight or hearing problems
  • Medications

If a person with Alzheimer’s begins hallucinating, it’s important to have a medical evaluation to rule out other possible causes and to determine if medication is needed. It may also help to have the person’s eyesight or hearing checked.

Coping strategies

When responding to hallucinations, be cautious. First, assess the situation and determine whether the hallucination is a problem for the person or for you. Is the hallucination upsetting? Is it leading the person to do something dangerous? Is the sight of an unfamiliar face causing the person to become frightened? If so, react calmly and quickly with reassuring words and a comforting touch. Do not argue with the person about what he or she sees or hears. If the behavior is not dangerous, there may not be a need to intervene. For more coping strategies,

Offer reassurance

  • Respond in a calm, supportive manner. You may want to respond with, “Don’t worry. I’m here. I’ll protect you. I’ll take care of you.”
  • Gentle patting may turn the person’s attention toward you and reduce the hallucination.
  • Acknowledge the feelings behind the hallucination and try to find out what the hallucination means to the individual. You might want to say, “It sounds as if you’re worried” or “I know this is frightening for you.”

Use distractions

  • Suggest a walk or move to another room. Frightening hallucinations often subside in well-lit areas where other people are present.
  • Try to turn the person’s attention to music, conversation or activities you enjoy together.

Respond honestly

  • If the person asks you about a hallucination or delusion, be honest. For example, if he or she asks, “Do you see him?” you may want to answer with, “I know you see something, but I don’t see it.” This way, you’re not denying what the person sees or hears, but you avoid an argument.

Modify the environment

  • Check for sounds that might be misinterpreted, such as noise from a television or an air conditioner.
  • Look for lighting that casts shadows, reflections or distortions on the surfaces of floors, walls and furniture. Turn on lights to reduce shadows.
  • Cover mirrors with a cloth or remove them if the person thinks that he or she is looking at a stranger.

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