Monday, October 31, 2011

How to Manage hallucinations and suspicion in Alzheimer’s Patients?

Alzheimer’s and Hallucinations

People with Alzheimer's disease may see, hear, smell, taste, or feel things that are not really there. The most common hallucinations are those that involve sight or hearing. Some people with Alzheimer's disease develop strange ideas about what is actually happening and may come to believe that other people want to harm them. This kind of belief is called a delusion.

These symptoms are usually thought of as being caused by mental illness, but they are actually fairly common in Alzheimer's disease, especially in the middle stage, although they can occur at other stages. There may be many causes mostly having to do with the parts of the brain affected by the disease. In any case, it is important not to be frightened by what are irrational thoughts and experiences and to know how to respond to them. Maintaining sameness and calmness in the environment can help reduce hallucinations. Also, violent movies or television can contribute to paranoia, so avoid letting the patient watch disturbing programs.

A number of symptoms of Alzheimer’s disease are labeled as "psychotic," hallucinations being one of them. Around 18 percent of people with Alzheimer’s disease experience hallucinations, and they are more often reported in people with a later disease onset. For the majority these are visual, for others they are auditory, with some having both. Experiencing hallucinations normally lasts from one to two years and occurs in line with declining cognitive functions.

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Some hallucinations are temporary, do not cause long-term difficulties, and are unrelated to mental illnesses. Sometimes, though, they can represent a major problem and specific treatment is needed. In addition to the dementia itself, there could be other causes for hallucinations including physical illness, fever and medications. In fact, many healthy people experience brief hallucinations at some time in their lives. But since they can 'test reality' or solve problems accurately, they are aware that these are not real, and as such, not worrying.  People with dementia may not be able to do this accurately.

Monitor and analyze any factors which may contribute in changes to the patient’s behaviors, such as:
  • Sensory defects such as poor eyesight or poor hearing.
  • Side effects of some medications.
  • Psychiatric illness as part of multiple diagnoses.
  • Recently changed and unfamiliar environment.
  • Inadequate lighting, making visual clues less clear.
  • Physical conditions such as infections, fever, pain, constipation, anaemia, respiratory disease, malnutrition, dehydration.
  • New and unfamiliar caregivers.
  • Disruption of familiar routines.
  • Misinterpretation of environmental cues often a result of forgetting to use a hearing aid or glasses.
  • Sensory overload because of too many things going on at once.

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Possible Reasons for Hallucinations?

Lewy Bodies

Alzheimer’s disease brains show disc-shaped plaques outside brain cells called neurons, and neurofibrillary tangles inside them. However, there is debate about whether these are the cause of hallucinations. There is better linkage between hallucinations and "Lewy Bodies," round masses inside neurons. Debbie Tsuang, in the American Journal of Geriatric Psychiatry's April 2009 edition, found these in nearly 2/3 of patients with visual hallucinations. A review by Antony Harding in the February 2002 edition of Brain, detailed how Lewy Bodies were shown in brain areas affected by Alzheimer’s disease, such as the hippocampus and amygdala, which are involved in emotional interpretation. Lewy Bodies are more often seen in Parkinson’s disease and dementia with Lewy Bodies--where hallucinations are one symptom. Harding suggests people with Alzheimer’s disease with hallucinations may also have one of these disorders.

The Occipital Lobe

The occurrence of visual hallucinations is not related to defects in the eyes or retinal connections to the brain, although visual problems may exacerbate hallucinations. Shu-Han Lin discusses in the November-December 2006 edition of Clinical Imaging how instead hallucinations are associated with a decreased occipital lobe, which is involved in visual interpretation. This has led some, including Suzanne Holroyd in the Journal of Neuropsychiatry and Clinical Neurosciences Winter 2000 edition to propose that hallucinations are due to damage to brain regions involved in vision and those that interpret visual signals, including the occipital lobe, the amygdala and the hippocampus.


APOE4 is one form of the gene for the protein apolipoprotein E, normally involved in neuronal functioning. APOE4 is found in around 15 percent of people and causes functional problems with apolipoprotein E, leading to an eight-fold risk for developing Alzheimer’s disease. Study results are mixed regarding whether APOE4 is involved in the development of hallucinations. While the Tsuang study above didn’t find an association, another, by Kristina Zdanys in Neuropsychopharmacology's January 2006 edition, found APOE4 associated with an increased risk of “visual disturbances.”

Another gene possibly involved in hallucinations is for the protein brain-derived neurotrophic factor, or BDNF, which is involved in dynamic neuronal changes. There are decreased amounts of BDNF in Alzheimer’s disease, in line with disease severity. One form of the BDNF gene was reported by Kristina Zdanys in the Journal of Alzheimers Disease July 2009 edition to be significantly linked to increased occurrences of hallucination.

A third gene is for one of the neuronal receptors for the brain neurochemical serotonin, called 5HT2A. Stimulation of this receptor can cause hallucinations, and a study by Antonia Pritchard in Neurobiology of Aging's March 2008 edition found a small association between hallucinations and one form of the 5HT2A receptor.

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How to Manage Hallucinations in Alzheimer’s Patients?

When hallucinations or illusions do occur:
  • It is essential that you do not tell the person who is seeing or hearing things that you know what he sees is not real because the things are real to the person.
  • Discuss the patient’s feelings relative to what they imagine they see. 
  • Respond to the emotional content of what the person is saying, rather than to the factual/fictional content. 
  • Reassure the person that you will keep him safe and try to understand the emotion behind the hallucination or delusion.
  • Physical contact may be reassuring as well, but be sure that the person is willing to accept this.
  • Hallucinations or false ideas may be harmless, and they are sometimes best ignored or accepted. If they don’t upset the person experiencing them, there may be no need for intervention. But be sure to report delusions and hallucinations to the person’s doctor to rule out physical or psychiatric illness.

This may be enough to enable the person to let go of these concerns, at least for the moment. If the hallucination is pleasant and the person is planning a birthday party, try to connect to her by joining in the fantasy. You do not need to say that you see or hear the same things but you can accept that the person does. Seek professional advice if you are concerned about this problem, and you feel it goes out of proportions. Medications can sometimes help to reduce hallucinations, and managing the prescriptions my easy the problem or even make it go away. 

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Alzheimer’s and Suspicion

People with Alzheimer's disease may also become suspicious and may accuse someone of stealing from them when they cannot find something. When the person with dementia does not remember where he put something, the idea that it has been taken by someone may appear to be a reasonable explanation for its being missing. Tell him you will help him look for it, and try not to mention the fact that he is the one who misplaced it. He may feel relieved when the object is found.

Paranoia in people with Alzheimer's disease appears as unrealistic beliefs, usually of someone seeking to do them harm. They may hoard or hide things because they believe someone is trying to take their possessions. These symptoms can be very distressing both for the person with AD and for you. Remember, what the person is experiencing is very real to him. It is best not to argue or disagree.

  • Try not to take unjust accusations personally. In this situation it is best to offer to help the person to find the missing item. It will not be helpful to try to convince him that his explanation is wrong or based on his poor memory.
  • Offer a simple answer to any accusations, but don’t argue or try to convince them their suspicions are unfounded.
  • Distract the patient with another activity. Distractions which may help include music, exercise, activities, conversations with friends and looking at old photos.
  • If suspicions of theft are focused on a particular object that is frequently mislaid, such as a wallet for example, try keeping a duplicate item on hand to quickly allay the patient’s fears.
  • Keeping a diary may help to establish whether these behaviors occur at particular times of the day or with particular people. Identifying such causes may help you to be able to make changes to overcome the difficulties.

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When these behaviors do not respond to supportive caregiving techniques it may be necessary to consider medication, especially if the person is very upset or puts himself or others in danger because of his symptoms. These symptoms are sometimes caused by depression, which often accompanies Alzheimer's disease. Consult with your physician, who may recommend an antidepressant medication. Other medications, called anti-psychotics, are frequently prescribed. They should be used with caution and sensitivity.

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