What does dementia-related psychosis look like?

According to a 2021 study, between 20% and 70% of people with dementia will experience psychosis at some point. So, what does dementia-related psychosis look like? It manifests primarily through hallucinations and delusions, causing a person to lose touch with reality and become distressed, fearful, or agitated.

Quick Summary

Dementia-related psychosis involves hallucinations and delusions, leading to a distorted sense of reality. Symptoms include seeing or hearing things that aren't there, paranoid beliefs, and misidentifying familiar people or places. These signs can fluctuate and are often accompanied by agitation, aggression, and anxiety.

Key Points

• Delusions: Psychosis often involves false, persistent beliefs, such as a loved one being an imposter (Capgras Syndrome) or family members stealing their possessions.

• Hallucinations: The individual may see, hear, or sense things that are not present, with visual hallucinations being particularly common in certain dementias like Lewy body.

• Misidentification: A person with DRP might fail to recognize their own reflection in a mirror, believing it to be a stranger.

• Paranoia: Intense and unfounded suspicion is a key feature, causing the person to believe they are in danger or being targeted.

• Behavioral Changes: Symptoms frequently accompany changes such as increased agitation, aggression, anxiety, and sleep disturbances.

• Non-Reality-Based Experience: It's essential to understand that the psychotic experiences are real to the person experiencing them, and confronting their reality is often counterproductive.

Core Signs of Dementia-Related Psychosis

Dementia-related psychosis (DRP) is a complex condition that adds another layer of challenge for both individuals with dementia and their caregivers. The defining features of DRP are hallucinations and delusions, which cause a person to experience a distorted reality. While dementia itself involves memory loss and cognitive decline, psychosis represents a more severe disruption of a person's thoughts and perceptions. It is a symptom, not a standalone illness, and can be triggered or worsened by the progression of the underlying dementia.

Hallucinations

Hallucinations are perceptions that occur without an external stimulus. In DRP, these can involve any of the five senses, but visual hallucinations are the most common, especially in certain types of dementia.

• Visual Hallucinations: Seeing people, animals, or objects that are not actually there. For example, a person might see a child in the room, a cat on the bed, or strangers in the house. These can be benign, but often cause distress or fear. The person may interact with these perceived figures or react in a way that seems out of place to others.
• Auditory Hallucinations: Hearing voices or noises that aren't present. While less common than visual ones, auditory hallucinations can occur. A person might hear conversations, whispers, or strange sounds.
• Other Hallucinations: Less frequently, a person may experience olfactory (smelling things that aren't there) or tactile (feeling phantom sensations) hallucinations.

Delusions

Delusions are unshakable, false beliefs that persist despite evidence to the contrary. They often involve paranoia, causing the person to feel threatened or suspicious of their loved ones.

• Paranoid Delusions: Believing family members are stealing their money, that caregivers are conspiring against them, or that they are in danger. A person might hide objects and then accuse others of theft when they cannot find them.
• Misidentification Delusions (Capgras Syndrome): Believing that a familiar person, such as a spouse, child, or caregiver, has been replaced by an imposter.
• Phantom Boarder Delusions: The belief that strangers are living in their home.
• Unfaithful Partner Delusions: Believing a spouse or partner is having an affair, often without any basis in reality.

Associated Behavioral and Psychological Symptoms

Psychotic symptoms are rarely isolated and can trigger a cascade of other challenging behaviors. These behaviors can be just as distressing for both the individual and their caregivers.

• Agitation and Aggression: Confusion, fear from hallucinations, and frustration from delusions can lead to severe agitation and aggressive outbursts.
• Anxiety and Fear: The constant feeling of being watched or believing that one is in danger can cause intense anxiety.
• Sleep Disturbances: Psychosis can disrupt the normal sleep-wake cycle, leading to nighttime agitation and wandering.
• Apathy: Some individuals with DRP may withdraw socially and show a lack of interest in their usual activities.

Dementia with Psychosis vs. Dementia Without Psychosis

Understanding the key differences between typical dementia and DRP can help in recognizing and managing the symptoms effectively. The table below outlines the distinctions.

Feature	Dementia Without Psychosis	Dementia-Related Psychosis (DRP)
Symptom Focus	Primarily cognitive decline, memory loss, and confusion.	Hallucinations (seeing/hearing things) and delusions (false beliefs) in addition to cognitive decline.
Nature of Distress	Distress is often related to memory problems, difficulty with tasks, and disorientation.	Distress is often caused by fear, paranoia, and confusion stemming from hallucinations and delusions.
Safety Concerns	Safety issues generally relate to forgetfulness, wandering, and impaired judgment.	Higher safety risks, including aggression, falls, fractures, and higher mortality rates.
Caregiver Burden	Significant, but primarily centered on managing cognitive and functional decline.	Intensified by managing psychotic episodes, paranoia, and related aggressive behaviors.
Response to Reality	May be confused but can often be redirected with patience and gentle reminders.	Often unable to be reasoned with, as the delusions feel completely real to them. Challenging the delusion can cause further distress.
Treatment Focus	Focuses on managing cognitive symptoms and maximizing function through environmental adjustments and support.	Requires non-pharmacological strategies to address triggers, alongside potential medication to manage severe psychotic symptoms.

What to Do When Psychotic Symptoms Appear

If you are caring for someone exhibiting DRP, several non-pharmacological strategies can help manage the symptoms and reduce distress.

• Identify Triggers: Look for environmental factors that may be causing distress. This could include glare from a TV, confusing reflections in a mirror, or shadows in a dimly lit room.
• Avoid Confrontation: Challenging a person's delusion or arguing about what is real can make them more upset and agitated. Instead, acknowledge their feelings and try to redirect their attention to a more comforting topic.
• Create a Safe and Calm Environment: Remove potential triggers and ensure the home is well-lit. Simple changes can help a person feel more secure and less threatened.
• Maintain Routine: Consistent daily routines can reduce confusion and provide a sense of stability, which can be helpful in managing unpredictable symptoms.
• Seek Medical Guidance: Consult with a healthcare provider to rule out other potential causes of the symptoms, such as an infection (like a UTI) or medication side effects. The doctor can also discuss potential medical treatments if the symptoms are severe and unresponsive to other methods.

Conclusion

Recognizing what dementia-related psychosis looks like is the first crucial step in providing effective care and support. The presence of delusions and hallucinations, often accompanied by increased agitation and aggression, distinguishes it from typical dementia symptoms. Understanding that these experiences are real to the person affected, rather than intentional acts, allows caregivers to respond with patience and empathy. By implementing environmental adjustments, using gentle communication techniques, and seeking professional medical advice, caregivers can navigate the challenges of DRP and improve the quality of life for their loved ones. While difficult, this approach helps alleviate distress and fosters a safer, more supportive environment. For more information and support resources, consider consulting the Alzheimer's Association.

Visit the Alzheimer's Association website for more resources

Frequently Asked Questions

How common is psychosis in people with dementia?

Psychosis is a relatively common symptom in dementia. Studies indicate that anywhere from 20% to 70% of people with dementia may experience it at some point during their illness, with rates depending on the type and stage of dementia.

Are hallucinations and delusions the only signs of dementia-related psychosis?

While hallucinations and delusions are the core symptoms, they are often accompanied by other behavioral and psychological changes, including increased agitation, aggression, anxiety, and sleep disturbances.

What is the difference between delirium and dementia-related psychosis?

Delirium is an acute and sudden state of confusion, often caused by an underlying medical issue like an infection. DRP is typically more gradual and stems from the brain's ongoing neurodegenerative changes, although delirium can sometimes trigger psychotic episodes in someone with dementia.

How should a caregiver respond to a delusion or hallucination?

It is not helpful to argue or reason with a person experiencing a delusion or hallucination, as their experience feels real to them. Instead, acknowledge their feelings, provide reassurance, and try to gently redirect their attention to another activity.

Can certain environmental factors trigger psychosis in dementia?

Yes, environmental factors can trigger or worsen psychosis. Examples include confusing reflections in mirrors, shadows that look like figures, changes in routine, or too much noise and stimulation.

Is there a specific medication for dementia-related psychosis?

While there is no standardized treatment, medication can be used in some cases, especially when symptoms are severe. Atypical antipsychotics may be prescribed, but their use requires careful consideration due to potential side effects.

What is the best way to manage accusations of theft from someone with dementia?

Instead of denying their claim, acknowledge their distress. Help them look for the 'missing' item together, perhaps suggesting a place where it is frequently misplaced. Often, redirecting them to another activity can help diffuse the situation.