Clinical Case Study of Hallucinations and Delusions in Dementia-related Psychosis in the Long-term Care Setting: An Expert Perspective

Roger G.*: 82-Year-Old Male With Mixed Dementia

  • Meet Roger, an 82-year-old male who was diagnosed with mixed dementia (Alzheimer’s disease dementia and vascular dementia) at age 75
    • He receives an acetylcholinesterase inhibitor and an NMDA antagonist as treatment for Alzheimer’s disease
    • Several other medications are used to treat Roger’s various neuropsychiatric symptoms
  • He has multiple comorbid medical conditions that also require treatment
    • Dyslipidemia, hypotension, chronic obstructive pulmonary disease, pulmonary fibrosis, cerebrovascular disease, coronary artery disease with mildly reduced ejection fraction
  • Roger currently lives in the secure memory care unit of a large, long-term care/nursing home facility
  • His family caregivers are his wife and adult daughter

Clinical Commentary

Alireza Atri, MD, PhD

Clinical Commentary

  • Mixed dementia is common and may have clinical implications. Postmortem pathology data show that more than half of individuals with dementia had multiple neuropathologies
  • To inform the diagnosis, Roger underwent evaluation with a structured history and multidomain symptom and function review, as well as a focused examination, to assess the level of impairment. Diagnosis was accompanied by laboratory tests and neuroimaging
  • Since diagnosis, Roger has received medications for Alzheimer’s disease. He also has experienced delusions associated with dementia-related psychosis. After these symptoms increased in correlation with an environmental trigger, it became clear that his treatment regimen was insufficient. Other medications were added for Roger’s neuropsychiatric symptoms as indicated

Case topic:
The nature of Roger’s hallucinations and delusions associated with dementia-related psychosis disrupts his care as well as that of other residents in the facility.

NMDA, N-methyl-D-aspartate.

Roger G.*: History of Delusions and Hallucinations

Following an unprovoked physical assault on Roger by another resident at the facility, the nature, frequency, and severity of Roger’s hallucinations and delusions associated with dementia-related psychosis progressed over a period of time.

Clinical Commentary

Alireza Atri, MD, PhD

Clinical Commentary

Alireza Atri, MD, PhD

Clinical Commentary

  • Initially after his dementia diagnosis at age 75, Roger’s delusions were mild and intermittent. His serene demeanor had a calming influence on other residents
    • Facility staff used nonpharmacologic interventions (eg, removing triggers, redirecting) to manage Roger’s behavior
  • About 1 year ago at age 81, Roger suffered an unprovoked physical assault in which another resident struck him. Since then, Roger’s symptoms have become more severe and occur on a daily basis
    • Roger has had multiple workups for these episodes of psychosis. Each workup has ruled out delirium and medical conditions as precipitating factors
  • With the increased symptom severity and risk to himself and others around him, I coordinated with facility staff and Roger’s family to develop a multipronged treatment approach to address his hallucinations and delusions associated with dementia-related psychosis

Consequences of Dementia-Related Psychosis

Roger*Roger’s Family Caregivers Facility Staff and Residents
  • Roger puts himself at risk when he resists medications and oxygen 
  • He has fallen down several times and injured himself 
  • His episodes have resulted in many trips to the ED
  • Taking care of Roger is costly in terms of time, money, and emotional distress
    • Multiple meetings between family and facility staff, social workers, and medical team 
    • Calls to family throughout the night to come and calm Roger 
    • Additional caregivers hired to care for Roger
  • Roger’s episodes interfere with his medical care and disrupt the care environment 
  • Roger has cycled through several roommates, each of whom have been moved for their own safety

    ED, emergency department.

    Clinical Commentary

    Alireza Atri, MD, PhD

    Clinical Commentary

    • Roger resists treatment because he believes he is being poisoned. This contributes to a vicious cycle: His dementia-related psychosis is inadequately treated, thereby exacerbating his symptoms and behaviors. He becomes paranoid and anxious
      • This knife edge is extremely challenging for the medical/nursing team and family to navigate
    • Overall, the consequences of hallucinations and delusions associated with dementia-related psychosis are substantial
      • On Roger: Increased frequency and severity of his delusions and hallucinations interfere with his care and impact his quality of life
      • On his family caregivers: His wife has reported depression; his daughter has difficulty balancing time at her job and tending to her father’s needs; and financially, Roger’s care is a burden
      • On facility staff and residents: Roger’s dementia-related psychosis requires all resources of the facility (nurses, case managers), who feel “pushed to the limit”

    “You implement and monitor a plan, yet there is a proportion of patients with dementia-related psychosis who may relapse if the disease is not managed properly. The practical challenge lies between addressing these disruptive symptoms and having the appropriate medications with which to do so safely and effectively.”
    Dr. Alireza Atri

    *Based on an actual patient. Patient details provided by Alireza Atri, MD, PhD. 

    Additional Contributor(s)

    Alireza Atri

    MD, PhD

    Banner Sun Health Research Institute
    Sun City, AZ

    Faculty Insights

    Dr. George T. Grossberg describes the nature of visual hallucinations that adults with dementia-related psychosis may experience.