Dementia hallucinations: what to do when he sees things

With dementia hallucinations, what to do first is decide whether it's scaring him. If your dad is chatting with a little girl nobody else can see and he's happy, you can often leave it alone. If he's frightened, don't argue about whether it's real. Tell him calmly that you don't see it, that he's safe and that you're staying with him, then move him to a bright room or a different activity. And if the hallucinations are new, call his doctor, because a treatable problem like an infection or a medicine can cause them.

It's unsettling to watch. He points at the corner and asks who the man is, and the hair on your arms stands up. Knowing what's going on, and having a few lines ready, makes it a lot less frightening for both of you.

Hallucinations vs delusions in dementia

These two get mixed up, and the difference changes what you do.

A hallucination is a false perception through the senses. The National Institute on Aging describes it as seeing, hearing, smelling, tasting or feeling something that isn't there. He might see his mother, who died years ago, sitting in the armchair. He might feel bugs on his skin.

A delusion is a false belief. The Alzheimer's Association defines delusions as firmly held beliefs in things that aren't real. He might be sure his wife is having an affair, or that you're stealing his money.

They can feed each other. A man who sees a stranger in the yard may decide someone is planning to break in. For the belief side, like accusations and suspicion, see the guide on when she accuses you of stealing. This guide covers the seeing and hearing.

Why dementia causes seeing things that aren't there

In Alzheimer's, hallucinations come from changes in the brain and usually show up in the later stages, according to the Alzheimer's Association. It gives examples such as seeing faces in the pattern of a curtain, seeing insects crawling on the skin, or hearing people talking.

In Lewy body dementia, they often come much earlier. The National Institute on Aging says visual hallucinations happen in most people with Lewy body dementia, often early in the disease, and are usually realistic and detailed, like children or animals. If your dad's hallucinations started early, or came with stiffness, a tremor, shuffling or acting out his dreams in his sleep, ask his doctor about it.

Other causes can be treated. The Alzheimer's Association lists infections such as bladder or kidney infections, dehydration, pain, eyesight or hearing problems, and medicines.

Dementia hallucinations: what to do in the moment

1. Ask yourself whether it bothers him. Pleasant or neutral hallucinations may need nothing from you. Fear is what you're there to calm.
2. Don't argue. The National Institute on Aging says not to argue about what he sees or hears, and to comfort him if he's afraid. Telling him "there's nothing there" usually makes him feel unheard or crazy.
3. Be honest without fighting. The Alzheimer's Association suggests something like saying you know he sees something, but you don't. That's true, and it doesn't call him a liar.
4. Check the room. Is there a coat on a hook, a shadow from a lamp, a reflection in a dark window? Is the TV or the air conditioner making a sound he could mistake for voices?
5. Move him. The Alzheimer's Association suggests a well-lit room with other people in it. A walk outside or a change of room often breaks the spell.
6. Distract him. Music, a snack, a conversation about something he loves, a simple task.
7. Keep him safe. The National Institute on Aging says to make sure he can't reach anything he could use to hurt himself or someone else. A frightened man may try to fight off an intruder only he can see.

What to say when he sees things

Short, calm lines work best. Say one, then give him a moment.

The last two lean into what he sees. That's a judgment call. If going along with it calms him and costs nothing, it can be kind. If it makes the experience more real or more frightening, step back to "I don't see it, but I'm here." The guide on therapeutic lying has a test for when going along is the right call.

Take Gloria, whose father started seeing a man standing by the hall closet every evening. She'd been telling him nobody was there, and he'd get angrier each time. Then she noticed the man showed up only after dark, right where his overcoat hung under the hall light. She moved the coat into the closet and put a brighter bulb in. The man stopped coming most nights.

Fix the room: light, mirrors and noise

Many hallucinations start as a misread shadow or sound. These changes come from the Alzheimer's Association and the National Institute on Aging.

• Get rid of lighting that makes shadows, reflections or glare. Turn lamps on before dusk and close the curtains so dark windows don't turn into mirrors.
• Cover or remove mirrors if he sees strangers in them.
• Turn off violent or upsetting TV. The National Institute on Aging notes that someone with Alzheimer's may think those events are happening in the room.
• Listen for sounds he might be misreading, like a fan, the dishwasher or a radio in another room.
• Use night-lights along the path to the bathroom.

When to call the doctor about hallucinations

The Alzheimer's Association says a person with dementia who starts hallucinating should have a medical evaluation, including eyesight and hearing checks. MedlinePlus lists hallucinations as a possible sign of delirium, which usually starts suddenly over hours or days and can be caused by infections like a UTI or pneumonia, or by a medicine.

Bring a list of everything he takes, including over-the-counter pills and supplements. Ask whether his type of dementia could explain what you're seeing, especially if Lewy body dementia hasn't been ruled out.

The doctor may raise medicine if the hallucinations are frightening or dangerous. That decision belongs with the doctor. The Alzheimer's Association notes that antipsychotics carry an increased risk of stroke and death in older adults with dementia. It also warns that in Lewy body dementia these drugs need extreme caution, because many people have serious reactions. Ask about the risks, and make sure every doctor he sees knows his diagnosis. Getting a reluctant parent to the appointment is its own problem, covered in the guide on when a parent refuses to see a doctor.

Questions caregivers ask

Why are dementia hallucinations worse at night?

Low light makes shadows, dark windows reflect, and he's tired after a long day. All of that makes it easier for his brain to misread what's around him. Brighter evening lighting and a calm, quiet evening routine help.

Do hallucinations mean dementia is getting worse?

Not always. In Alzheimer's they tend to come later, but in Lewy body dementia they can appear early. A sudden change is often something else, such as an infection or a medicine. That's why new hallucinations call for the doctor, whatever the stage.

What if he sees bugs on his skin?

Take it seriously, because it feels real to him. Check his skin for a rash, dryness or bites, since a real itch can start it. Brush his arm gently, offer lotion, and tell his doctor.