Treating Adults With Dementia-Related Psychosis

Hallucinations and delusions can be deeply unsettling—for you and your loved one. Here’s how to manage them.

Maybe your husband of 40 years is suddenly having audible, animated conversations with his mother—who died thirty years ago. Or your wife is certain you’re cheating on her, and her accusations are angry, intense, and sometimes violent—even though you spend your days, 24/7, selflessly tending to her every need.

When dementia with psychosis strikes, it can be frightening—for both you as a caregiver and your loved one. And treating the hallucinations and delusions that come with it can feel like a top priority.

Hallucinations are imagined sensory experiences that can involve seeing, hearing, tasting, touching, or smelling things that are not truly there. Delusions are false perceptions that have no basis in reality. Both can range from harmless episodes to aggressive, even disturbing outbursts. Such symptoms—also known as psychosis—can emerge in all forms of dementia, including Alzheimer’s disease, Lewy body dementia, and Parkinson’s disease. Currently, 2.4 million people in the U.S. are thought to be battling dementia-related psychosis, according to the Alzheimer’s Association.

Medicine can reduce or eliminate hallucinations and delusions. But, these treatments come with side effects and some pretty serious risks, including death. So, you and your loved one’s doctor will want to rule out other causes of psychosis first. You’ll also want to explore what you can do to help reduce hallucinations and delusions without medication. Here, our experts will walk you through everything you need to know to best treat your loved one with dementia-related psychosis.

Hallucinations and Delusions May Have Other Causes

When you first notice the signs of psychosis in your family member with dementia, you may jump to the conclusion that their dementia is the cause. However, that may not be the case.

“Sometimes, what appears to be a delusion is a misperception,” says Melinda Lantz, M.D., vice chair and chief of geriatric psychiatry for Mount Sinai Beth Israel in New York City. “People with dementia don’t always perceive things as accurately as others. Also, people with dementia often have hearing loss and vision loss, so it’s easy for them to misinterpret things that they see or hear.”

Before using medication to treat what may seem to be psychosis, a doctor will want to rule out other possible causes, such as:

  • Vision loss

  • Hearing loss

  • A change in routine or caregiver

  • Pain

  • Under- or overstimulation

  • Medications that may cause hallucinations

  • Infection, such as a urinary tract infection

Rx Treatment May Not Be Necessary

You don’t want to put a relative with dementia on unnecessary medications—especially not antipsychotics that can bring serious risks and side effects, warns Rodolfo Savica, M.D., a neurologist who treats patients with dementia at Mayo Clinic in Rochester, MN. If the delusions or hallucinations are not hurting you or your loved one, medicine might not be necessary, he adds.

“If my patient tells me, ‘I see things, but they’re not really a problem in my daily life; I know they’re not there, and I can just look away,’ then I am not going to treat it that aggressively,” Dr. Savica says.

However, sometimes delusions and hallucinations can cause your family member extreme distress or anxiety. Delusions can even lead some people to refuse food, water, or medical care.

“I’ve had patients who have become paranoid to the point that they won’t take their pills, or go to a doctor’s appointment, or leave their apartment,” Dr. Lantz says.

Paranoid delusions can also lead to aggressive or violent behavior. For example, a person with dementia may become violent with a caregiver they suspect of stealing or a spouse they suspect of infidelity.

“By the time caregivers come to see me for help, they may already have bruises from the person they are caring for,” Dr. Lantz explains.

But if the symptoms of psychosis don’t cause physical or psychological problems for you or your relative, you will want to weigh that against the potential risks and side effects of treatments.

Managing Psychosis Without Medication

For people whose psychosis does not put anyone in danger, doctors might recommend that you make changes at home to help manage hallucinations and delusions.

“I tell caregivers, ‘distract and redirect,’” Dr. Savica says. When your loved one is, for example, interacting with a hallucination, you should gently distract them and help shift their attention to something else.

Here are other ways you can help reduce psychotic symptoms for your loved ones:

  • Engage your loved one in regular activities, including exercise, music, arts, games. “Anything to keep their mind active and engaged in positive things will [help] prevent their mind from wandering,” Dr. Lantz says.

  • Arrange your home to prevent events that trigger delusions. For example, make sure your mother’s purse is always by her chair so that she doesn’t think someone stole it.

  • Keep interactions positive, soothing, and calm, adds Dr. Lantz. Don’t confront, argue, or disagree about delusions or hallucinations. In response to an accusation of theft, you might simply say, “Your purse is right here.” In response to a hallucination, it’s not necessary to say, “There’s no one there.” You can instead say, “Who are you talking to? Well, why don’t you come over here and talk to me now?”

Managing Psychosis With Traditional Medications

Doctors use antipsychotic medication to treat psychosis if the psychotic symptoms are very distressing for your loved one—or dangerous for either of you. These drugs are a last resort because they come with a black box warning about the increased risk of death in older adults who take them.

The black box indicator is the FDA’s strongest warning about risks or side effects from drugs or medical devices. The risk of death is highest right after a person starts the medication. The larger the dose, the higher the risk of death.

These drugs cause side effects, too, including sedation, brain fog, restlessness, and movement problems such as tremors. These can increase agitation and increase risk of falls and other accidents.

“Feeling restless or having tremors can make the psychotic symptoms worse because they’re going to feel physically uncomfortable,” Dr. Lantz says. “Geriatric providers read all about the medications and try to pick the ones that are going to have the most favorable side effect profile.”

Doctors can try to reduce risks and side effects by prescribing as little as possible for as short a period as they can. Traditionally, doctors will start at a low dose and use the medication for as brief a period as possible. Dr. Lantz typically starts patients on a low dose and monitors them closely for both positive results and side effects over a few months. Within six months, she says, most patients can go on a lower dose or taper off altogether.

Doctors may soon have another drug in their arsenal. Nuplazid (pimavanserin) is a new member of the atypical (or second-generation) antipsychotics drug class, currently FDA-approved for hallucinations and delusions associated with Parkinson’s disease, also called Parkinson’s disease psychosis. It joins drugs like Risperdal (risperidone) and Clozaril (clozapine), and is also being evaluated by the FDA for the treatment of dementia-related hallucinations and delusions. (A decision is expected in Spring 2021.) It would be the first drug indicated to treat these symptoms of dementia.

The drug comes with the same black box warning as other drugs in class. But, an FDA analysis of its safety concluded that the benefits of this drug outweigh the risks. Like with other drugs in its class, people with delusions and hallucinations may only take it for a short time.

“Antipsychotics are not at all a lifelong or long-term commitment,” Dr. Lantz says. “It’s about getting the symptoms under control and seeing if we can make everyone feel better.

Sonya Collins
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Sonya Collins

Sonya Collins is an Atlanta-based independent journalist and editor. She covers health, medicine and scientific research, with a special emphasis on genetics and personalized medicine. Sonya is a regular contributor to WebMD Magazine, WebMD.com, CURE, and Staying Sharp. She is a contributing editor at The Conversation and WebMD.com.