Alzheimer's and Hallucinations
People withAlzheimer's disease may see, hear, smell, taste, or feel things that are notreally there. The most common hallucinations are those that involve sight orhearing. Some people with Alzheimer's disease develop strange ideas about whatis actually happening and may come to believe that other people want to harmthem. This kind of belief is called a delusion.
These symptomsare usually thought of as being caused by mental illness, but they are actuallyfairly common in Alzheimer's disease, especially in the middle stage, althoughthey can occur at other stages. There may be many causes mostly having to dowith the parts of the brain affected by the disease. In any case, it isimportant not to be frightened by what are irrational thoughts and experiencesand to know how to respond to them. Maintaining sameness and calmness inthe environment can help reduce hallucinations. Also, violent movies ortelevision can contribute to paranoia, so avoid letting the patient watchdisturbing programs.
A number ofsymptoms of Alzheimer's disease are labeled as "psychotic,"hallucinations being one of them. Around 18 percent of people with Alzheimer'sdisease experience hallucinations, and they are more often reported in peoplewith a later disease onset. For the majority these are visual, for others theyare auditory, with some having both. Experiencing hallucinations normally lastsfrom one to two years and occurs in line with declining cognitive functions.
Some hallucinations are temporary, do not cause long-term difficulties, and areunrelated to mental illnesses. Sometimes, though, they can represent a majorproblem 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 hallucinationsat some time in their lives. But since they can 'test reality' or solveproblems accurately, they are aware that these are not real, and as such, notworrying. People with dementia may not be able to do this accurately.
Monitor and analyzeany factors which may contribute in changes to the patient's behaviors, suchas:
- 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.
Possible Reasons forHallucinations?
Lewy Bodies
Alzheimer'sdisease brains show disc-shaped plaques outside brain cells called neurons, andneurofibrillary tangles inside them. However, there is debate about whetherthese are the cause of hallucinations. There is better linkage betweenhallucinations and "Lewy Bodies," round masses inside neurons. DebbieTsuang, in the American Journal of Geriatric Psychiatry's April 2009 edition,found these in nearly 2/3 of patients with visual hallucinations. A review byAntony Harding in the February 2002 edition of Brain, detailed how Lewy Bodieswere shown in brain areas affected by Alzheimer's disease, such as thehippocampus and amygdala, which are involved in emotional interpretation. LewyBodies are more often seen in Parkinson's disease and dementia with LewyBodies--where hallucinations are one symptom. Harding suggests people withAlzheimer's disease with hallucinations may also have one of these disorders.
The Occipital Lobe
The occurrence ofvisual hallucinations is not related to defects in the eyes or retinalconnections to the brain, although visual problems may exacerbatehallucinations. Shu-Han Lin discusses in the November-December 2006 edition ofClinical Imaging how instead hallucinations are associated with a decreasedoccipital lobe, which is involved in visual interpretation. This has led some,including Suzanne Holroyd in the Journal of Neuropsychiatry and ClinicalNeurosciences Winter 2000 edition to propose that hallucinations are due todamage to brain regions involved in vision and those that interpret visualsignals, including the occipital lobe, the amygdala and the hippocampus.
Genes
APOE4 is one formof the gene for the protein apolipoprotein E, normally involved in neuronalfunctioning. APOE4 is found in around 15 percent of people and causesfunctional problems with apolipoprotein E, leading to an eight-fold risk fordeveloping Alzheimer's disease. Study results are mixed regarding whether APOE4is involved in the development of hallucinations. While the Tsuang study abovedidn't find an association, another, by Kristina Zdanys inNeuropsychopharmacology's January 2006 edition, found APOE4 associated with anincreased risk of "visual disturbances."
Another gene possibly involved in hallucinations is for the proteinbrain-derived neurotrophic factor, or BDNF, which is involved in dynamicneuronal changes. There are decreased amounts of BDNF in Alzheimer's disease,in line with disease severity. One form of the BDNF gene was reported byKristina Zdanys in the Journal of Alzheimers Disease July 2009 edition to besignificantly linked to increased occurrences of hallucination.
A third gene is for one of the neuronal receptors for the brain neurochemicalserotonin, called 5HT2A. Stimulation of this receptor can cause hallucinations,and a study by Antonia Pritchard in Neurobiology of Aging's March 2008 editionfound a small association between hallucinations and one form of the 5HT2Areceptor.
Another gene possibly involved in hallucinations is for the proteinbrain-derived neurotrophic factor, or BDNF, which is involved in dynamicneuronal changes. There are decreased amounts of BDNF in Alzheimer's disease,in line with disease severity. One form of the BDNF gene was reported byKristina Zdanys in the Journal of Alzheimers Disease July 2009 edition to besignificantly linked to increased occurrences of hallucination.
A third gene is for one of the neuronal receptors for the brain neurochemicalserotonin, called 5HT2A. Stimulation of this receptor can cause hallucinations,and a study by Antonia Pritchard in Neurobiology of Aging's March 2008 editionfound a small association between hallucinations and one form of the 5HT2Areceptor.
How to Manage Hallucinations inAlzheimer'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 beenough to enable the person to let go of these concerns, at least for themoment. If the hallucination is pleasant and the person is planning a birthdayparty, try to connect to her by joining in the fantasy. You do not need to saythat you see or hear the same things but you can accept that the person does. Seek professional advice if you are concerned about thisproblem, and you feel it goes out of proportions. Medications can sometimeshelp to reduce hallucinations, and managing the prescriptions my easy theproblem or even make it go away.
Alzheimer's and Suspicion
People withAlzheimer's disease may also become suspicious and may accuse someone ofstealing from them when they cannot find something. When the person withdementia does not remember where he put something, the idea that it has beentaken by someone may appear to be a reasonable explanation for its beingmissing. Tell him you will help him look for it, and try not to mention thefact that he is the one who misplaced it. He may feel relieved when the objectis found.
Paranoia inpeople with Alzheimer's disease appears as unrealistic beliefs, usually ofsomeone seeking to do them harm. They may hoard or hide things because theybelieve someone is trying to take their possessions. These symptoms can be verydistressing both for the person with AD and for you. Remember, what the personis 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.
When thesebehaviors do not respond to supportive caregiving techniques it may benecessary to consider medication, especially if the person is very upset orputs himself or others in danger because of his symptoms. These symptoms aresometimes 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. Theyshould be used with caution and sensitivity.
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