Sometimes delusions are created by the “time travel” phenomenon that comes with dementia when people lose either the ability to separate the layers of time and/or their sense of place. Sometimes the “destinations” are past events that represented major milestones or accomplishments – scenarios in which the person had independence, control, and power, and used them well. If dementia caregivers are able to identify the triggers of happy delusions, they may be able to leverage such delusions to help those living with dementia experience those feelings again.
But other times, the delusions involve unhappy events, memories or fictional narratives of the present. Unlike dementia-related hallucinations, there is a plot or story line when delusions of the present occur.
EXAMPLE:
When the elevator door dinged open on her brother’s floor, Jill immediately heard a faint but beautiful singing. As she approached Stanley’s room, the singing became louder. Once standing right outside his door, she could make out the song – “Amazing Grace” – in a lacy, high-pitched voice wafting through the opposite door, ajar, and past the “Welcome Sylvia!” balloon tied on the door knob. Stanley was near tears as Jill crossed his threshold. “They are killing residents here and throwing them down the trash chute! It’s horrible! You can hear them scream!”
This narrative (a real-life delusion but names were changed, as with all client examples) was extreme but very real to Stanley. In his delusional state, Stanley was visibly and extremely agitated as he told his daughter this news. Jill tried to comfort him without questioning what he believed was very real. “Oh dear! I see you’re shaking. Can I give you a hug?” she asked.
In this scenario Stanley’s delusion was an attempt to explain circumstances that didn’t make sense to him. The circumstances that trigger delusions often don’t make sense to a person with dementia because the ability to process visual, auditory, tactile, or other stimuli has been compromised by their dementia. The delusion becomes the only “logical” explanation for the mysterious circumstances they can no longer process, and is an attempt to fill in missing information with imagined details.
Join their reality
Jill was correct to validate Stanley’s feelings. Rejecting his theory would only damage the trust he placed in his daughter – a trust that was essential to his well-being as he gradually lost his independence, control, and power over his own circumstances. In her response, Jill communicated that she understood the problem as Stanley saw it, that he had a right to be upset, and that she was supportive of him. Jill’s response was an excellent example of how a dementia caregiver might join the reality of a person living with dementia.
Similar to delusional accusations, there is usually no one specific to blame in negative delusions. An amorphous “they” if often the culprit in these delusions.
What environmental factors could have contributed to Stanley’s fears? Were there objects or images that reminded him of bad memories, or past physical or emotional trauma? If so, Jill might have removed them to eliminate triggers for negative delusions.
It is quite difficult to attend to events that are not actually occurring. It might seem easier to try to assure a person living with dementia with a rational response like, “No, you’re just imagining things.” However such a response can only make things worse. When dementia caregivers deny the events described to them by a client or family member with dementia, they will become one of the enemy.
That is why Jill continued her initial validation with “Yes, and this is scary. Tell me more.”
Indulge your curiosity
Simultaneously, her response was an attempt to fish for clues that might help her connect her father’s delusion to stimuli surrounding him and further validation of his reality. She also probed, “When does this happen?” to try to connect the dots for herself. It also further signals that she believes her father’s version of reality.
Simply validating a person in dementia-related delusion can help de-escalate the situation. When Stanley’s agitation diminished after Jill’s validation, it was easier for her to redirect his attention. Attempting to change the stimuli around him by changing his environment, she suggested they go to the cafeteria for a cup of coffee.
When they entered the hallway, the singing began again. “See what I mean? Can you hear the screaming?” Stanley asked. Then it dawned on Jill. Stanley misinterpreted the shrill, high-pitched vibrato of Sylvia’s singing as screaming!
All she had to do was knock on the new neighbor’s door, introduce her father, and ask Sylvia to sing for them. Now Stanley could see the source of the “screaming” and begin to form an explanation for the noise he couldn’t explain before.
It took several re-introductions to help Stanley overcome this delusion, but eventually he moved on from the negative narrative that caused him so much anxiety and fear. Without Jill’s curiosity and compassion, his delusion may never have been resolved.