Understanding and Managing Delusional Behavior
By Mary Adam Thomas
Larry Washington’s* car had been stolen. He was extremely upset and angry about it, particularly because he suspected the staff members at the facility where he lived were part of the ring of thieves responsible. Larry’s care providers knew that he was exhibiting signs of paranoia sometimes seen in individuals suffering from Alzheimer’s disease (AD) and other forms of dementia. But when they gently reminded him that he no longer owned a car, he only got more agitated.
Then one of the nurses had an idea. She went to a separate section of the building and placed a call to Larry’s floor, asking a colleague to hand the phone to him. “Mr. Washington? I understand your car’s been stolen,” she said. “I’d like to take a report and submit it to the police for you.” Larry answered a few of her questions about his car but soon tired of the conversation and hung up, calmly turning his attention to something else. Most of what Larry needed during this instance of paranoia was to feel heard. Empathy and compassion were delivered in the proper dose.
Facing Paranoia Head-on
Larry’s episode is the kind of behavior Maureen Nash, M.D., sees regularly and counsels families about often. As the medical director of Providence ElderPlace in Portland, Oregon, Dr. Nash works with older adults, most of whom are dealing with cognitive impairment. And, according to studies, as many as one-third of people suffering from dementia also experience delusions and/or paranoia.
“Paranoia is a subset of and related to delusions,” explains Dr. Nash, who is board-certified in internal medicine and psychiatry. “Delusions are fixed, false beliefs while paranoia involves fearfulness that comes from misinterpreting information—such as thinking that things are dangerous to you or others even though they are not.”
According to Dr. Nash, there are numerous ways in which paranoia shows up among dementia patients. Most commonly, she says, it is secondary to something else. A person who has misplaced her keys, for example, might conclude that someone has stolen them. “Paranoia can be a response to memory impairment in a person who isn’t aware that her memory is impaired. This unawareness of impairment is present in about two-thirds of people with Alzheimer’s,” says Dr. Nash.
In other instances, a person might believe someone is trying to harm him or someone he loves. “When someone with dementia is experiencing the normal aches and pains that come with aging, he might assume that he has been beaten up because his memory loss prevents him from forming any other logical conclusion,” notes Dr. Nash. “It’s a paranoid explanation for things that he can’t otherwise explain.”
Predicting the Whens and the Wheres
Some dementia patients experience paranoia on a fairly constant basis, while others (like Larry Washington) have episodes of paranoia that come and go. Some people who have been suspicious all their lives exhibit no signs of paranoia after dementia sets in. The reverse can also be true: Some people with no history of such behavior begin to develop paranoia as a component of cognitive impairment.
“It all depends on which part of the brain is impacted, in what order the brain problems develop and how the disease progresses over time,” notes Dr. Nash. “We don’t currently have a good way of predicting how, if at all, these things will occur in any one person.”
Pursuing Pharmaceutical Solutions
Medications that are designed for dementia patients have been shown to decrease paranoia and delusions in certain cases. Dr. Nash reports seeing moderate and even dramatic improvement in some of her patients—particularly those with AD and Lewy body dementia—after being prescribed cholinesterase inhibitors (such as Aricept®, Razadyne® and others).
Anti-psychotic medications can also be helpful for treating paranoia and delusions in the memoryimpaired. “Unfortunately, dementia is defined as a cognitive illness instead of a behavioral illness,” notes Dr. Nash. “That has led some people to pay less attention to the behavioral, psychological and psychiatric improvements these medications can provide. There is a place for them, especially if the dementia medications aren’t enough and someone is suffering gravely with paranoia.”
Coping With It
There’s no one way to prevent delusions among the cognitively impaired, but caregivers can use these general tips to help themselves and their loved ones manage these challenging situations if and when they do arise:
Be prepared. Episodes of paranoia and/or delusions are unfortunate but not uncommon among people suffering from dementia. Prepare yourself emotionally for the possibility that your loved one will experience this so you can respond appropriately.
Remain calm. Be as non-reactive as you can be, reassuring the person that everyone is safe and everything is secure. Respond to their emotions, not their words.
Honor the person’s reality. Remember that the paranoia is coming from your loved one’s illness and feels very real to them. Don’t try to convince them that what they assume to be true is actually false. Your reality is not relevant.
Recognize the fear. Paranoia can look like anger, but almost always stems from fear. And fear can make anybody feel extremely powerless and uncomfortable. Be compassionate in the midst of your loved one’s fear and reassure them that you’ll keep them safe.
Explain your actions. It’s easy for a paranoid person to misinterpret the actions of the people around them, particularly when memory loss makes it difficult for them to recall who those people are. So over-explain what you’re doing, especially if you’re coming in direct personal contact with the individual—even if you’ve performed the same task many times before.
*Name changed to protect privacy.