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Delusions in Dementia, Part 1

Delusions are defined as false beliefs. These delusions can occur anytime in the dementia journey and they usually run their course then fade away. For this blog, I’m going to write about the three of the most common types of delusions that are encountered when caring for a person living with dementia: persecutory, jealousy, and scarcity. I’m also going to write about where these false beliefs may be coming from. In next week’s blog, I’m going to offer ways to deal with these false beliefs. But don’t stop reading! In order to develop individualized strategies to handle these delusions, you need the information provided right here!

Delusions are sometimes confused with hallucinations and illusions. Hallucinations are seeing, hearing, feeling, tasting, or smelling things that no one else is experiencing. Hallucinations are common in PDD and Lewy Body dementia. They may also pop up in the other dementias. Illusions are mis-perceiving an object, like seeing a coiled garden hose on the ground and thinking it is a snake. I once scared the crap out of myself—and everyone in my house—when I woke up from a deep sleep and saw a strange man standing at my bedside, peering down at me. I screamed in fright and jumped up. My son and daughter came rushing into my room. When Sara flipped on the light, I realized that the “stranger” was a large hoodie that I had been too lazy to put away and had tossed it over the bedpost.

Quick note: psychologists and psychiatrists tend to think of delusions and delusional thinking within the context of mental health illnesses—like schizophrenia. The important piece for you to remember is that the presence of a delusion in a person living with dementia does not mean that they are mentally ill. Rather, these false beliefs are the result of brain changes associated with dementia, and the subsequent mixed-up memories and emotions associated with those memories. 

Persecutory (Paranoid) Delusions

One of the most common types of delusion encountered in people living with dementia is persecutory, meaning someone is trying to harm them. You may see delusions early in dementia as the person tries to make sense out of a situation. For example, picture a woman in her mid-70s. She has mild dementia but maybe has not been diagnosed. She has lived her current home for 25 years. For the past 25 years, she always placed her house and car keys in the candy dish on the little table by the front door. Today, she walks past the candy dish and enters the kitchen. She opens a cabinet to pull out a drinking glass. At the same time, she places the keys inside of the cabinet. She is focused on getting a drink of water and immediately forgets that she put her keys in the same cabinet as the drinking glasses.  

Because she ALWAYS placed her keys in the candy dish, she has multiple past memories of doing so—25 years’ worth of memories. In her mind, she put her keys in the candy dish and now the keys are nowhere to be found. When she finally locates the keys in a cabinet, she decides that a family member is moving her keys on purpose. As more familiar items “disappear,” she may become very suspicious and have delusions of people stealing from her.

When people living with dementia experience persecutory delusions, you may find yourself the target. You may be accused of poisoning their food, stealing their money, or taking their things. Or, your family member may be convinced that someone “out there” is trying to get into the house and hurt them.

Seemed like a good idea at the time…

Sometimes, family members unwittingly “start” persecutory delusions by how they handle challenges. I have had family members remove vehicles and firearms from the possession of the person living with dementia. The family then tells the person living with dementia that those items were stolen. I understand why the family members told this lie: they needed to make the environment safe for the person living with dementia and for others. But they accidentally created a whole new problem. Being robbed creates feelings of vulnerability and violation for everyone. These feelings in a person living with dementia, combined with the progressive memory loss, can cause the perfect environment for a persecutory delusion.

Delusions and Prior Mental Health

Persecutory delusions may also be an extension of the person’s pre-dementia mental health. Do you know people who truly believe that everything and anything is “out to get them”? I do. These people personalize everything. They are cosmic “Eeyores,” moping around their lives and failing to see the good stuff, always fixated on perceived slights and insults. If your family member fits this description, then it makes sense that persecutory delusions ramp up as memory issues arrive.

Anosognosia Versus Delusion

A related false belief that many carers encounter early in the dementia journey is the “I’m fine, I don’t need any help (or supervision)” false belief. This way of thinking is not considered a delusion. It comes from something called anosognosia. Anosognosia is a failure to recognize one’s limitations despite evidence to the contrary. Anosognosia happens because people forget that they forgot.

Jealousy Delusions

I’m paying for the sins of her first husband.

–Dementia Spousal Caregiver

This sad statement came from a loving husband who was caring for his wife living with dementia. This was a second marriage for both. Her first husband was a real tool. In addition to being violent, he had had multiple affairs. He was not discrete and his wife often found evidence of his affairs. When she confronted him, he “lied like a rug.” Husband #2 was the opposite. They had 25 good years together and then she developed dementia. Husband #2 provided excellent care. However, when this woman entered the moderate stage of dementia, she suddenly started to accuse her current husband of having affairs. Her perception of time was also altered. When he left the house to go collect mail from the mailbox, his return was greeted with, “Where have you been? I’ve been looking for you for hours.” The poor woman would then retreat to the bedroom and sob for hours.

When she accused her current husband of having affairs, he understandably became defensive, even angry. Here he is caring for her, making sure she is OK, and she is accusing him of having affairs? Her current husband did not make the connection between his wife’s distant past and her current behavior until I asked questions and started to connect the dots. His new insight and knowledge did not change her behavior. It did change his perception of the behavior and helped him to try several strategies—which I’ll share in next week’s blog. The knowledge and insight also changed his “vibe,” which might have been fueling his wife’s delusions.

Sometimes, jealousy delusions represent old fears and old insecurities. My own father had a very public affair when I was in middle school. In fact, I walked in on my father and his girlfriend making out on the family room sofa while my mother was working her 3-11 shift. Let’s just say everyone was very surprised. Since that experience, I have had no experiences with unfaithful spouses—at least not to my knowledge. Should I develop dementia and be in a relationship, I may show jealousy delusions based on my old fears and insecurities that stemmed from my adolescent memories.

Scarcity Delusions

Your family member may have a fixed, false belief that their money is running out…or that they have no money…even though the bank statements say otherwise. They may tell you that they have not eaten, and they are starving, because there is no food in the house…but you check the fridge and pantry and there is a ton of food…and some of it is spoiling!

Scarcity delusions often show up in people who have experienced past food insecurity or past poverty. Sometimes, family members tell me, “That never happened. They were always well off.” True, your loved one—based on YOUR memories—has always been financially OK or never experienced homelessness or hunger. Is it possible that something happened that you don’t know about? For example, I was working with a man whose father was a successful entrepreneur and ultimately sold his company for millions. My client’s father, who was in the mild-to-moderate stage of dementia, was convinced that they were bankrupt. This delusion created havoc with the people his son had hired to allow his father to safely stay in his home; his father would tell everyone to leave because he had no money to pay them. His son was confused about the bankruptcy delusion. He knew that his father had had some “lean times” when the business was getting off the ground, but it had become wildly successful—and remained so until the business was sold. I suggested that my client ask his father about bankruptcy the next time the topic arose. I also suggested reaching out to living relatives who were around the same age as his father. About a week later, I received an excited phone call. Turns out, his father HAD filed for bankruptcy for an earlier business that failed before my client was even born. The situation was so bad that his parents had to postpone their wedding plans. His maternal grandmother even tried to break the engagement and convince her daughter to marry someone else. This bit of family history was never shared with my client or his siblings. Even though his father became a successful business owner, his first failed venture was a source of deep shame and embarrassment to my client’s father.

Bottom Line

Delusions can range from the mildly amusing to the extremely hurtful. Delusions do not mean that your loved one living with dementia has psychiatric problems or are mentally ill. Next week: how to handle the delusions.

Categories: Dementia

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Dr. Rita Jablonski

Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.

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