Late Stage Symptom: Psychosis & Delusions

As Alzheimer’s disease progresses, symptoms change and become more pronounced at each stage, particularly the behavioral symptoms. While the physical and cognitive changes can be challenging, the behavioral symptoms can be particularly distressing. While there are treatments and strategies to help manage behavioral symptoms, there is no cure for Alzheimer’s disease, and no treatment will fully stop the symptoms or slow down its progression. The aim of these treatments is to help mitigate symptoms, and various lifestyle modifications can help minimize disruption and improve quality of life.

Psychosis and delusions are often referred to as “behavioral and psychotic symptoms of dementia” (BPSD) when they’re present in those with Alzheimer’s disease.¹ Symptoms that may accompany the psychosis and delusions include hallucinations and sundowning. It is estimated that more than 90% of those with dementia have at least one BPSD.¹

Symptoms

The term psychosis refers to a break from reality and includes symptoms like hallucinations (seeing or hearing things that aren’t there) and delusions (belief in things that aren’t real).² To the person with Alzheimer’s, the things they are experiencing are very real, which can make this very hard to watch for loved ones and caregivers. When a person with Alzheimer’s disease exhibits symptoms of psychosis or delusions, they might have symptoms like:

• Hearing, seeing, smelling or feeling things that aren’t there. For example, a person may see small children playing that are not there.
• Believing that family members are stealing from them
• Believing that they’re being followed or monitored by the police
• Feelings of suspicion or jealousy

Disorganized speech or behavior might also be present, and this can be part of psychosis.

When to see a doctor

If a person with Alzheimer’s disease starts exhibiting symptoms of psychosis or delusions, see the doctor immediately. This is not always due to Alzheimer’s disease; it can also be a side effect of a medication interaction or another medical condition, which is why it’s important to be evaluated by a professional. Determining the underlying cause of the psychosis or delusions will guide the treatment approach.

Coping tips

Although there are medications like antipsychotics that can help treat psychosis and delusions, they are not generally first-line treatments. Non-drug treatments should be tried first, since medications can have serious side effects. These strategies not only help the person with Alzheimer’s disease try and re-center themselves and calm down, but they can also help caregivers remember that the patient is unable to help themselves, and aren’t trying to be difficult. Some strategies to try when a person with Alzheimer’s is exhibiting psychotic symptoms include^1,3,4:

• Distraction: take them for a walk, bring them into another room, etc. Sometimes a change of scenery or activity can make all the difference.
• Assess for pain or toileting needs
• Comfort: listen to the person’s concerns and don’t argue with them; provide comfort if they are afraid or upset, and don’t tell them what they see or hear is not real.
• Safety: make sure they are safe and don’t have access to anything that could harm them or others.
• Keep it simple: provide short answers that aren’t complicated
• Try to stick to a routine
• Make eye contact, get on their level, and don’t intrude in their personal space
• Refrain from scolding, and instead, validate their feelings and concerns
• Remove distractions such as clutter; turn off the TV if it is upsetting

If hallucinations and delusions become alarming, to the point the person may harm themselves or others, call 911.

If these approaches don’t work, it might be necessary to use medications to treat the psychosis or delusions, especially if the symptoms are severe or the person is at risk for harming themselves or someone else.

Medications

Although antipsychotic drugs exist, there is no drug that is specifically approved by the FDA for behavioral and psychiatric symptoms related to Alzheimer’s disease.⁵ When these drugs are used in Alzheimer’s disease and other neurocognitive impairment disorders, they are used “off-label,” or used for a different purpose than that for which it’s typically prescribed. Antipsychotic medications like haloperidol (Haldol), risperidone (Risperdal), or aripiprazole (Abilify) may be prescribed for symptoms like hostility, delusions, aggression, and hallucinations. Talk with the doctor about the risks and benefits of taking an antipsychotic medication, since these drugs have been shown to increase the risk of stroke and death in Alzheimer’s patients.⁵ In addition, these drugs can increase falls or cause severe motor symptoms, especially if the person has another neurodegenerative disorder that is not Alzheimer’s disease such as dementia with Lewy bodies. Careful monitoring of the person with Alzheimer’s taking these drugs is important.

If psychosis and delusions are present, a thorough medical evaluation should be done to rule out any other cause (infection, vitamin deficiency, etc.), and then appropriate treatment plans can be made.