Brain changes from dementia can cause hallucinations, delusions or paranoia. According to Heathman, MD, a Houston psychiatrist, “paranoia, or having false beliefs, is a common trait of later stage dementia. However, it can occur in all stages of dementia.”
What Do We Mean By Paranoia?
Sometimes our loved one living with dementia will believe something we do not. When this results in undesirable emotions such as fear, jealousy or anger, we call it paranoia. It is generally the secondary emotions we are upset by. With the term, paranoia, comes an implicit judgment and the implications that, “My reality is real, your reality and your feelings are not.”
The best thing we can do to alleviate ‘paranoia’ is to discard this judgment. Start from a place of “our realities are real and different.” For the person experiencing paranoia, their reality is as real to them as yours is to you and mine is to me. For the sake of understanding in this article, I will use the term ‘paranoia’. My hope is that after reading it you, like me, will not find a use for the word anymore.
How to Help Soothe Paranoia in Dementia
We can provide reassurance and support so those experiencing paranoia feel safe and loved. Do not fall into the trap of detailed explanations or logical arguments. Try these behavioral techniques to calm someone living with dementia, who is experiencing paranoia.
What we call paranoia in dementia feels very real for the person living with it. It is their reality. Susan London, LMSW, Director of Social Work at Shore View Nursing and Rehabilitation says that, “There is often no evidence that will convince them otherwise.” Try the following in response to your loved one:
1. Rule out non-dementia causes of paranoia.
Heathman stresses that, “to understand paranoia in dementia, you need to understand its cause. Paranoia can result from urinary tract infections, liver disease, systemic infections, and anxiety disorders. In many instances, treating those may put an end to the paranoia.” Rule out possible causes outside of dementia. Schedule an appointment with a physician to rule out treatable conditions.
2. Validate their reality.
Do not attempt to present “proof” a belief is false. Nor should you deny that the evidence is real. Both approaches could create an intense unfavorable emotional reaction from your loved one.
Imagine I told you it is October 2nd, 2087 and you do not live in your home, it is gone. How do you feel? Is there anything I can say to convince you your reality isn’t real? No, trying to do so will only cause upset. This is the same for people living with dementia.
“Take the example of a woman looking for her deceased husband. She is certain that he is in the house. Telling her that he died a long time ago, or showing his death certificate, will make matters worse.” says London. The best thing you can do is to honor her reality. Lying can lead to more confusion and upset. Validation techniques offer a way to do this without lying.
Acknowledge what your loved one is feeling. Then work to meet the need they are expressing. In the case above, you could start by saying, “You’re looking for your husband.” Then, try to uncover the unmet need looking for her husband is expressing. Does she need help with something her husband usually did? You could ask, “Is there anything I can help you with?” Does she miss her husband? You could say, “Tell me about your husband.” Get curious and uncover the ‘why’ behind looking for the deceased husband. Once you know the ‘why’ you can try to meet that need another way.
3. Avoid proving them wrong.
The best way to defuse paranoia is to acknowledge the person’s reality. From there you can explore what is needed and meet that need. Imagine telling this woman her husband is deceased. She may not acknowledge his death to be true and could be very hurt by that thought. The news could also cause her to re-experience the trauma of his loss or she may strike out in anger, accusing this person of “killing her husband.”
4. Stay honest.
This is a fine line to tow. You want to validate the other’s experience but you do not want to make-up or add to their reality. In this example, imagine saying “your husband will be home later.” While at the moment this seems kind, it is not the best option. By fibbing you start a third reality. Now there is her reality, your reality and the made-up reality. This can lead to more confusion. She might wait for her husband now. Then what do you say later in the day when she expects him to be home and you have told her he would be? You will have to keep fibbing. Each one will take you further away from the unmet need ‘looking for her husband’ is expressing.
5. Remain calm.
“Remember that you are not to blame for what your loved one is experiencing,” says Heathman. “Although witnessing a hallucination can be scary, it’s important to stay calm. Remember that arguing ‘something is not real’ is not helpful.”
Stay calm by:
- Practicing meditation techniques to develop your own skillfulness at remaining calm.
- Taking three deep breaths before responding.
- Having a plan in place to prevent violence or call for help. If the situation escalates, act on your plan.
6. Be cautious before responding.
Assess the situation before responding to the person’s delusions. Is anyone at risk of harm?
If not, it’s often best to ignore the behavior stemming from a false belief. “As long as the behavior does not become dangerous, you might not need to intervene,” Heathman says.
For example, your loved one is walking around repositioning the placemats on the table and refolding the napkins. You ask them what they are doing and they say “my boss is coming back soon and I need to have all of the tables in the restaurant set or I will get fired.” Refolding napkins does not harm anyone. The unmet need here may be one of purpose or they may be anxious. In both cases, offering help would meet the need and allow you to connect with them.
7. Offer reassurance.
What if your loved one is upset, or wants your help? Get curious about what they are upset about and see if there is anything you can do to help.
For example, imagine your loved one is walking quickly yelling, “Help, I have to get out of here!” When you ask them what is wrong they tell you, “I am a prisoner here and I need to escape.” Ask if they would like to leave. If they say yes, go for a walk or a car ride.
Oftentimes, upset can also be calmed through reassuring physical touch combined with reflecting their reality. For example, if your loved one says, “I’m scared, I don’t know why I am here,” you could hold their hand or rub their back. Then you could say, “You are scared and don’t know why you are here. It will be okay. I am here with you.”
8. Shift attention.
“In some instances, it’s possible to put an end to a delusion or for it to drastically subside if the person’s attention is shifted.You can even try turning on lights or opening blinds. Frightening hallucinations often subside in well-lit areas and if others are present,” says Heathman.
Try talking about a favorite topic. Turn on their favorite song. Suggest you both work on a puzzle together. Try this once and if it does not work, try another technique that uses more validation. Trying this repeatedly if it is not working can lead, understandably, to even more upset. Imagine if you were trying to tell someone about something bad that was about to happen and they kept asking you about sports. Frustrating.
9. Ask open-ended questions.
“Avoid being judgmental. Asking questions that are open-ended is very healing for everyone involved,” says Becky Siden, LMSW, CDWF a licensed psychotherapist in Birmingham, Michigan.
When communicating with a loved one with dementia, Siden suggests focusing on being understanding. She says some helpful things to say or ask include:
- How can I help you to feel safe?
- Let’s look at this together and see how we can come up with a plan.
- I know the feeling of being scared and I am here to help.
- Tell me more about what this is like for you.
10. Shift attention.
“It’s very important to assess the reality of the situation,” stresses Heathman. For example:
- Glare from a window may look like snow to a person with dementia. Close the curtains to remove the glare.
- A dark area rug may look like a gaping hole your loved one believes she will fall into. Remove the rug to remove the black hole.
- Your mother may see a scary stranger in her reflection in the mirror. Cover the mirror with a sheet.
- Turn on more lights to reduce shadows that could look frightening.
One elder I worked with believed he was imprisoned and being experimented on. When I explored this further his evidence included:
- The doors were locked with codes only some people knew
- People took notes on his activity such as eating, bathing and going to the bathroom
- He overheard people lying to other ‘prisoners’
- Every time he asked to leave, the person changed the subject
- There were cameras all over.
He lived in a memory care facility. All of this evidence was true in both of our realities. Our conclusions are what differed. Modifying the environment to feel less clinical would have helped him to not feel he was imprisoned and experimented on.
11. Yes, and...
The tenants of improv and dementia can go hand-in-hand. They can be very helpful in forming meaningful interactions. The first step is ‘yes, and’. Whatever the other person says, say yes first. Acknowledge their reality. Then build on what they said to keep the connection going.
Imagine someone says, “They are out to get me, I have to hide.” You could respond with, “You feel they are out to get you and hiding will help. Where should we hide?” From this place of co-conspirators, the conversation could continue. From here you could get more information about why they feel they need to hide. You can then change the environment or meet the unmet need another way. Using improv helps you keep the interaction going so you can learn more.
Imagine if instead, you had responded, “No one is out to get you, just sit down it’s dinner time.” This would likely have lead to frustration and upset for both of you.
Summary – Do’s and Don’ts for Paranoia in Dementia
- See a doctor to check for other causes of paranoia.
- Try to avoid using the word paranoia and look for the underlying emotion.
- Acknowledge that you know that they are seeing or experiencing something.
- Acknowledge their feelings, fear, anger, frustration etc.
- Search for the unmet need they are expressing.
- Share that you are there to help.
- Remain calm.
- Ask open-ended questions.
- Modify the home environment to eliminate the source of scary objects.
- Have a plan in place and someone to call if things become harmful to you or them.
- Don’t be judgemental.
- Don’t show “proof” that the paranoia is unwarranted.
- Don’t make-up explanations you know to not be true.
- Don’t respond with “logical” explanations.
- Don’t deny the evidence is real.
- Don’t say you see something which, in your reality, you don’t.