Paranoia and delusions in dementia can range from the seemingly ridiculous, for example when they suddenly think a denture-thief is on the loose, to the heartbreaking when they think a loving spouse is being unfaithful or accuse family members of stealing from them. Or it can get downright bizarre if they think the FBI is after them or aliens are controlling their thoughts.
Sometimes the delusions last a moment, and sometimes it seems like they are living in their own world.
Unfortunately this is an all-too-common experience in dementia, with 30-40% of people diagnosed with Alzheimer's or another form of dementia experiencing delusions. Paranoid delusions are the most common.
What is a delusion? Basically it is a firmly held belief that is not real. A paranoid delusion is one that has a flavor of someone being "out to get them" in some way. A delusion is an error in thinking, which is different from a hallucination, which is an error in perception. With hallucinations, people will see, hear, feel, taste, and even smell things that are not there.
Why do delusions happen? Delusions are most common in the mid to late stages of dementia. As their brain deteriorates, there are more and more blank spots created by confusion, memory loss, loss of reasoning ability, impaired emotion regulation that need to be filled in. Delusions are the brain's way of trying to make sense of a world that is making less and less sense to them. Which also heightens their anxiety...and anxiety and panic are notoriously inaccurate when it comes to filling in blanks, often reaching for worst-case scenarios. Part of it is also just dysfunction in part of the brain being attacked by disease.
If they can't remember where they placed something, then it must be stolen. If they can't account for your whereabouts and remember where you've gone, then you must be off cheating.
When should you check with the doctor? If the paranoia and delusions are a sudden change in behavior, it's worth checking in with the doctor. There are some cases where the delusions are reversible, if it's part of an infection or something else putting them in a state of delirium. Some medication interactions can bring on delusional thinking.
If their delusions lead to aggressive or dangerous behavior, for their safety and the safety of others, medication may be appropriate.
10 Tips for Handling Delusions
Don’t take it personally. Remember that it’s the disease and their brain is trying to fill in the blanks. They are confused and lacking the usual skills needed to properly make sense of what is happening around them.
Join their reality. Don’t argue with them or try to convince them or show them “facts” that will set them straight. It won't work. What they believe is real for them, so allow them to express their thoughts and feelings. Imagine how you would feel if you believed what they believe, and offer comfort and reassurance for those feelings.
Keep it simple. Any answer you give them should be short and simple. Avoid long explanations that would be hard for them to follow.
Check their environment. Do some detective work to see if the delusions repeat in any particular way, if there are triggers you can identify. Does extra background noise add to their confusion? Do they have trouble with mirrors or strangers or new information? Are they more delusional when they are anxious? Is it more often in the morning or at night?
Stick to routines. Keep their daily routine as consistent as possible. Structure and consistency can help keep anxiety in check, which can give their brain fewer gaps to try to fill in.
Maintain dignity. Sometimes what they believe can seem pretty outlandish or impossible, but avoid telling them they're being ridiculous or stupid, don't be harsh about whatever mistaken thought they're having. They can't help what their brain is telling them. Embarrassing them or pointing out their confusion might make the situation worse.
Distract and redirect. Once you've let them know you've heard them, distract them with another activity or topic of conversation and redirect their attention. Offer them a snack or a drink, engage them in helping you with a task, go for a walk, ask them questions about something else. You can also bridge from the topic they're fixated on or upset about to a neutral subject.
Keep duplicates. If there's an item that they commonly misplace or lose, if possible buy several of that item so that you can offer one of the extras.
Get others on board. Explain what's happening to friends and family, let them know any accusations aren't actually about them. Encourage them to react calmly and gently.
Don't go it alone. For caregivers, dealing with delusions can be difficult on a day-to-day practical level, but can even be traumatic and extremely hurtful on an emotional level. Get support. Talk to friends and family, join support groups (in-person or online) and talk to others coping with similar situations, see a dementia coach or counselor to give you tools to respond to your loved one's particular delusional beliefs.