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Delusions in Dementia (Part 2): Strategies and Approaches

In last week’s blog, I described three common types of delusions that you may encounter when caring for a person living with dementia: persecutory delusions, jealousy delusions, and scarcity delusions.  There are other types of delusions, but these are the ones that tend to show up most often in people living with dementia.

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In this blog, I want to cover how to respond to and manage these delusions. Full disclosure—this information comes from my own clinical experience and knowledge of neurodegenerative changes that happens in the dementia brain. Sites like the National Institute of Aging and the Alzheimer’s Association have very general approaches. I have not been able to find any good approaches in the professional literature, either.  These are not one-size-fits-all approaches; rather, these strategies are a place to start when you are dealing with delusional behavior. When I have clients who work with me to get help dealing with delusional behavior, we usually devote one session on developing tailored strategies that fit their family member living with dementia.

General Approaches

Respond Without Defensiveness

When you are accused of something you haven’t done, it is natural to defend yourself. It is natural to go on the offensive.  This approach makes things worse in Dementia Land. If you immediately deny the accusations, you will simply amp up the situation and create more arguments.  Your loved one living with dementia will get angrier or more upset, which may fuel the delusion even more.

Respond to the Emotion

In addition to hearing the content, pay attention to the emotion that is coming through.  Is your loved one sounding frightened? Angry? Frustrated? My favorite go-to, and it is effective, is to simply respond, “You sound ____.” Wait a couple of seconds and then say, “I want to help.” Say this in a gentle, neutral way.

Here is why this approach often works. There is a saying in neurology: “neurons that fire together, wire together.” Emotions get tied to the delusion. You may notice that a certain emotion—like feeling frightened or feeling alone—happens before the delusional behavior starts. When you acknowledge the emotion, and then follow up with a desire to help, you are validating the person living with dementia and de-escalating the emotion. It may take a couple rounds of repeating “You sound ____.  I want to help.

Specific Strategies

Persecutory (Paranoid) Delusions

If the trigger for paranoid behavior is missing objects, you may want to keep multiple identical items handy. As I mentioned in another blog, my family member was always misplacing her wallet and ID cards. I kept the originals in a safe place but made laminated originals. When I gave her a new wallet for her birthday, I made sure that I bought four duplicates of the wallet. These 4 duplicates had the laminated IDs in place, too. My family member always misplaced these items in my house, so I wasn’t worried about identity theft. I knew the wallet would turn up later…in the laundry, or between the mattress and headboard, or between furniture cushions.

The next idea was left as a comment on one of my FB posts. I’ve never tried it, but it is worth a mention because it is very creative. One of my followers was caring for a family member with dementia who thought her food was being poisoned. This caregiver bought a small, empty spray bottle and filled it with water. She printed a label on her computer. The label had the word “poison” in black bold capital letters with a light red “X” over the word.  In smaller print, the label said, “Directions: Spray on your food. If there is poison, the food will turn bright orange immediately.” Underneath the directions, she printed, “Active ingredient: dihydrogen monoxide.” This is a chemical term for water. Pure genius!

Jealousy Delusions

Caregivers who experience accusations of infidelity feel compelled to present logic. In the case of a husband who was being accused by his wife of having affairs, he responded: “I walked to the mailbox and back. How in the world could I be with another woman?” Logic does not work in Dementia Land. Instead, respond with something simple, such as “I love you. I would never do that.” Or, you may want to try a variation on the approach I described above: “You sound upset. I love you and want to help.”

In case you are wondering why I keep suggesting that you incorporate “I love you” into your approach, it is because of the energy, the vibes, present in those words. Specifically, your energy and your vibes. Many times—but not always–spouses who provide care unconsciously shift their energies. They no longer act like lovers.  They stop the kisses and the cuddles and the gentle, romantic touches. Instead, they go into full-blown caregiver mode. Their touch becomes task-focused: washing, wiping, sliding on clothes. Caregiving is exhausting, so the last thing the spousal caregiver thinks about is kisses and cuddles. In fact, sometimes spousal caregivers actively dislike their spouse and resent the caregiving role. Not all of the time, but we are imperfect human beings and many of the dementia behaviors can test our patience. This shift in energy can be felt by the person living with dementia and may cause feelings of loneliness or rejection. Those feelings can then spark the jealousy delusions.

Again, if this sounds like it could be your situation, I am not saying you CAUSED the delusion. Nope. I’m describing the unconscious and subtle changes that happen over time and may fuel the delusion.

What if you are “paying for the sins” of a previous spouse? Here is one approach I’ve tried with some success. In the case of the husband who was being accused of having affairs by his wife with dementia, I instructed him to have 2 pictures of his wife: one with her first (and yucky) husband, and one with him. When she started to accuse him of cheating, he would hand her the first picture and ask her to tell  him about the people in the pictures. This technique also served as a type of distraction. When she said, “That’s me and John (husband #1),” her current husband would say, “Yes, that’s right. John was not good to you.” His wife would then reminisce for a bit. She would say a few sentences about John’s poor behavior. Once she finished, her current husband handed her the second picture and said, “Who are the people in this picture?” “Why, that is you, Paul, and me.” Her husband would then talk about the positive events that were going on when the picture was originally taken. “Yes, that is us. That was the trip to California. We had a great time.” Paul would continue to walk her down memory lane, focusing on the good times they had together and telling her how much he loved her.

Like noticing an incoming storm, Paul became really good at noticing when his wife was going to become upset and anxious and fall into the jealousy delusions. Paul would bring out the scrapbooks and derail the delusions.

I hate to bring this up, but…what if the affairs really happened? What if there is a history of infidelity? I’m not a marriage therapist or a family therapist. I honestly am not sure how couples move through infidelity. What I do know is that previous difficult experiences tend to resurface as people living with dementia move backwards in time. There is even literature on this topic—how Holocaust survivors with dementia believe they are back in the camps because they are gradually losing their memories so that the only accessible ones are the ones from their distant pasts. Borrowing from this body of literature, it is likely that people living with dementia who experienced a traumatic past event may reconnect with those buried memories and find themselves reliving some version of it.

Should your spouse be reliving a past event involving infidelity, it may help to use some of the same strategies that helped you both move past it the first time. You may want to enlist the services of a licensed therapist with solid dementia behavioral training who can assist you with this specific situation.

Scarcity Delusions

As I’ve written earlier in this blog, using logic and bank statements to convince your family member that they are financially secure may not be effective. You likely tried that already, and maybe the bank statements worked for a little while. Sincere reassurance is an approach that tends to work. When your family member expresses concern about not having money or having enough money, you can reassure them: “I’m handling everything (or “I’ve taken care of the bills”). “You are safe.” “You have enough money to (pay the bills, stay in the house, pay the nurses).” Another effective approach that works around scarcity delusions involving medications and medical bills is to simply say, “Insurance covered that,” or “Medicare is paying those bills.”

Sometimes, your loved one living with dementia may express fears that a specific individual has access to their finances and is stealing from them, resulting in poverty. This is an example of scarcity and persecutory delusions overlapping. You can use a version of the previous scripts described here: “It’s OK, I made sure that [name of person] can’t touch your money. Your money is safe.”

Bottom Line

When you are trying out different scripts, it is important to keep the language simple and direct. Do not launch into long explanations; this is tempting to do because it is how we are wired! We have long histories of offering long and logical explanations to strengthen the initial statements. Please avoid this temptation. You will only succeed in making the situation worse.

Once you find a script that works, stick to it. It is better to use 2-3 very short sentences and repeat them. And repeat them some more. You will feel like an audio loop. Your loved one will respond. Although you are aware of the repetition, they are not—thanks to the loss of short-term memory. As you repeat the same phrases over and over, the phrases will feel increasingly authentic to you. That feel of authenticity will come across and will help the phrases work even more when faced with the different types of 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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