Clinical Case Study in Hallucinations and Delusions Associated With Dementia-related Psychosis: An Expert Perspective

John M.*: 64-year-old Male With Dementia With Lewy Bodies

  • Meet John, a 64-year-old male with dementia with Lewy bodies (DLB)
  • At age 58, John started to experience:
    • Cognitive symptoms at work (ie, losing his train of thought during important meetings, failing to follow up with colleagues)
    • Early visual hallucinations
  • He lost his job soon after the symptoms began
  • John was diagnosed with DLB at age 60
  • He lives at home; his wife, Maureen, is his primary caretaker

Clinical Commentary

Rhonna Shatz, DO

Clinical Commentary

  • Dementia with Lewy bodies (DLB) can be difficult to diagnose; many clinicians who care for dementia patients focus on Alzheimer’s disease (AD) dementia
  • The early onset of visual hallucinations is a sign of DLB
  • Clinicians should suspect DLB, even in the absence of other symptoms
  • Even if an individual has AD, DLB could develop; it is possible to have 2 pathologies

Case topic:
John’s hallucinations and delusions associated with dementia-related psychosis places a significant strain on him and his wife, who is his primary caretaker.

John M.*: History of Delusions and Hallucinations

John has been experiencing hallucinations and delusions since his diagnosis of dementia with Lewy bodies 4 years ago.

Hallucinations/Delusions Frequency Impact/Severity
Seeing a person in the room (day or night) out of the corner of his eye Continuous and daily Distressing; disturbs his sleep; he closes the blinds, locks the doors, and hides behind the couch
Saw a figure on the road while driving Intermittently Distressing and physically dangerous to himself and others; the appearance of figures in the road caused him to brake and swerve
Delusions targeting Maureen:
  • Capgras syndrome (ie, spouse has been replaced by an identical impostor)
  • Delusions of infidelity
Continuous and daily Distressing and disturbing for John and Maureen; interferes with relationship and intimacy

Clinical Commentary

Rhonna Shatz, DO

Clinical Commentary

Rhonna Shatz, DO

Clinical Commentary

  • It is important to question the patient directly—not just the caregiver or another informant—to gain insight into true visual hallucinations that can point to DLB
  • It can be difficult to distinguish true visual hallucinations from a belief that something from the past is happening in the present
  • True visual hallucinations include seeing figures, people (familiar or not), and animals without an external/physical stimulus
  • Faces may or may not be distinctive

Delusions targeting the spouse/caregiver:

  • Fled the house thinking Maureen, his wife, is going to kill him
  • Paranoid that his wife will divorce him and/or put him in a nursing home
  • Accused his wife of having an affair
  • Sometimes thinks his wife is a stranger

Impact on the spouse/caregiver:

  • As a result, Maureen reports substantial impact on her mental and physical health
    • Emotional strain and physical health strain
    • Depression
      • Maureen has trouble getting out of bed in the morning and has “no desire to eat”
      • She “doesn’t have time” to make a healthcare appointment for herself and is afraid to leave John alone, so she hasn’t received treatment
  • She has been neglecting the needs of her children and grandchildren
  • Maureen feels that institutionalization of her husband may be the only option

Clinical Commentary

Rhonna Shatz, DO

Clinical Commentary

  • As a result of these symptoms, John is upset, and Maureen is fearful and feels vulnerable: Will John become violent? Will he harm himself, her, or others?
  • How can Maureen diffuse the situation? Bear in mind that hallucinations and delusions are illogical; therefore, logic will not help and may, in fact, escalate the problem
  • Remember the 3 R’s: Right, Reassure, Redirect
    • The patient is always right. Speak to the spirit of what the patient believes, eg, “Yes, I do look like Maureen. I have met her before”
    • Next, reassure, eg, “I am sorry she is missing. You must be so worried”
    • Finally, redirect. Change the patient’s environment to “reset” his or her brain, eg, “Let’s have some coffee in the kitchen”

“The accusation of having an affair is very hurtful, even when it is known to be part of the disease. It feels like the loss of their partner.”
Rhonna Shatz, DO

*Based on an actual patient. Patient details provided by Rhonna Shatz, DO.

Additional Contributor(s)

University of Cincinnati
Cincinnati, OH

Faculty Insights

Dr. Marwan Sabbagh offers insights on how distressing delusions and hallucinations can be to people with dementia-related psychosis and their families and health care providers.