Disturbances of Perception
I remember working on a military hospital’s orthopedic ward several years ago. This ward was a collection of rows upon rows of beds with only a curtain separating each patient. Those on this ward were treated for assorted ailments, and several had broken bones, amputations, or were otherwise bedridden. Mrs. S was tethered to an oxygen tank and seemed very anxious. She was pacing in the tiny, curtained area that was no larger than two hospital beds wide and just deep enough to walk around her bed. Curtains were almost always open as patients shared TVs that were suspended from the ceiling. Mrs. S. saw me approach and asked who I was. I told her my name, that I was a volunteer, and did she need anything? She said yes, she needed me to go to the Post Exchange, the store on base, and buy her a pack of cigarettes.
Instead of telling her that I did not have my ID to gain access to the store, I told her I could not do that because there was no smoking allowed on the ward. (I did refrain from reminding her she was on oxygen, which probably would have intensified her response.) She yelled, loud enough for anyone on the entire floor to hear, “You b----!! What good are you then?” Needless to say, I gave her a wide berth after that. Did she need to be reminded she was tethered to an oxygen tank? Or that she could not—and should not—smoke? Nope. I just happened to be the person she could respond to in anger at that moment. Was she in touch with reality? Perhaps. Did she realize the repercussions if she did get to smoke on the ward? Definitely not. Or she just did not happen to care at that moment.
Deirdre’s husband did odd things, like pacing non-stop at night and putting picture frames inside her panty hose. He could not explain why when asked and didn’t even seem aware that he was doing anything odd. Deirdre was more concerned with his wandering.
And then there was Mrs. P, a nice lady on the oncology ward with a shaved head and the unmistakable blue ink on her forehead that marked where her brain surgery had taken place. Mrs. P’s daughter welcomed me warmly as I entered her room. I learned that Mrs. P used to swim for hours a day; that she was always well groomed and poised and could converse with anyone at a party. Mrs. P napped in a chair in her private room while the two of us talked quietly. Soon, her daughter had to leave, and I stayed with Mrs. P until she awoke a few moments later. Mrs. P said hello and then went to stand by the window overlooking the hospital parking lot. I joined her, and we looked at the cars, or so I thought. Mrs. P told me those elephants marching by were quite impressive, and didn’t I agree? Not to contradict her, I told her I did not know the circus was in town, but they were indeed quite impressive. She continued that they were pinker than she thought they would be, and I nodded my head. Was Mrs. P hallucinating? Probably. Was she lucid? I am not sure what the exact definition of lucid is, but she could certainly hold a conversation about what she saw or thought she saw. I did not see a need to tell her there weren’t any elephants in the parking lot. What good would that do?
The reasons for experiencing hallucinations and delusions in dementia are unknown. The results of the BEHAVE-AD, a test for behaviors occurring in patients with Alzheimer’s disease, has shown that approximately 40% of individuals with AD at GDS stage 5 (midstage dementia with moderately severe cognitive decline) have the delusion that people are stealing from them. This delusion was found to be the most prevalent delusion in AD (Reisberg et al, 1996). This same percentage (40%) of AD patients at this stage also indicated symptoms of depressed mood. Of the 120 individuals with AD, the author listed the specific delusions and hallucinations reported by the BEHAVE-AD results. The delusions included: people stealing, ‘one’s house is not one’s home’, a spouse or caregiver is an imposter or is unfaithful, and the delusion of abandonment.
By definition, a delusion is a belief that is firmly held despite evidence to the contrary. Merriam-Webster defines a delusion as ‘a persistent false psychotic belief regarding the self or persons or objects outside the self that is maintained despite indisputable evidence to the contrary’. (delusion. (n.d.). In Merriam Webster Online. Retrieved October 10, 2018, from https://www.merriam-webster.com/dictionary/delusion). A hallucination is “the perception of objects with no reality usually arising from disorder of the nervous system or in response to drugs (such as LSD)”, again from Merriam-Webster. (hallucination. (n.d.). In Merriam Webster Online. Retrieved October 15, 2019 from (https://www.merriam-webster.com/dictionary/hallucination). The categories of hallucinations experienced by the AD patients in the Reisberg et al (1996) sample include visual, auditory, olfactory (scent/smell), and haptic (relating to sense of touch). A typical haptic hallucination might be the sensation of bugs crawling on a person’s skin. Hallucinations of taste (gustatory) were not mentioned in this sample’s reports. An example of an auditory hallucination was told to me by a friend. She said she remembers the exact moment she realized her father needed monitoring during the day. She came home after work one evening to find he had pulled out a section of sheetrock from the wall because there were worms digging around in there and they were so loud, he just had to do something about it.
Regardless of the type or subject of these reality distortions, what the client is describing IS their reality and any attempt to persuade otherwise with facts or explanations is typically futile and can be extremely frustrating to both client and caregiver. In each of these instances, one might feel the need to correct, instruct, or otherwise refute the behavior or belief. How would we feel if what we said was discounted? Acknowledge what they are feeling, seeing, or hearing and then attempt to distract them to another activity or subject. Endless questions are not purposeful. Corrections are not helpful. Provide reassurance that you are there to keep them safe, then attempt to segway into purposeful behavior.
If the distortion appears to be related to something in the environment (a mirror, background noise, dim lighting) correct those issues. Journaling can help decipher patterns in these instances—not just the time of day, but where they occur and how often. This is useful information for both the caregiver and the physician. Some medications (even antibiotics) have been associated with hallucinations in the elderly – both with or without dementia.
Hallucinations and delusions do not have to be negative, positive experiences may also occur.
Source:
Reisberg B, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer’s disease (BEHAVE-AD) rating scale. International Psychogeriatrics, 1996;8(Supp 3):301-308.