Older People

Mental health care


  1. Older people and psychotic-like experiences
  2. Behavioural and psychological symptoms of dementia
  3. Alzheimer’s disease
  4. Dementia with Lewy bodies
  5. Common hallucinations and delusions experienced by people with dementia
  6. Treatment – antipsychotic medication
  7. Other medication
  8. Other ways of supporting someone with dementia who experiences delusions and hallucinations
  9. Who will decide about treatment?
  10. Late life schizophrenia

Older people and psychotic-like experiences

At some point or another, there are many older people who experience delusions and hallucinations. If your elderly relative begins experiencing this, you should get a doctor to check the cause. Delerium, also known as ‘acute confusional state’ is a frequent cause of visual hallucinations, delusions and confused thinking amongst older people. Those who experience delirium will find it hard to concentrate and they will be disorientated. For example, they might not know what has happened, who people are or where they are. If an older person has an infection – a chest infection or UTI (urinary tract infection) for example, they will often experience delirium. This can also happen with a fever or dehydration. There are also medicines that can cause delirium and it is common for older people to have mental confusion after having an operation. In fact, research shows that as much as 60 per cent of older people experience delirium following surgery.

When doctors are able to identify the physical problem and treat it, the delirium should start to improve. For example, when a person has a UTI and begins taking antibiotics, their symptoms of delirium, delusions and hallucinations will also peter out.

Also, the older generation is more likely to have problems with their sight and, therefore, might not be able to see things properly due to poor lighting. Mistakes made because of this are sometimes misinterpreted as hallucinations. In a similar way, hearing should be checked as auditory hallucinations that a person experiences could actually be a result of bad hearing.

Delusions and hallucinations in older people can also have psychotic depression as their root cause, or alcohol and drugs. There is a very small number of older people with these experiences that do develop schizophrenia. Many elderly people also have psychotic-like episodes due to having dementia.

Behavioural and psychological symptoms of dementia

There are many different conditions and illnesses that can cause dementia – front-temporal dementia, dementia with Lewy bodies, vascular dementia and Alzheimer’s disease, for example. The Alzheimer’s Society reported that there were around 800,000 dementia sufferers in 2012. A significant number of these people experience delusions and hallucinations at some time during their illness.

The experiences of delusions and hallucinations aren’t always there – symptoms fluctuate but often become a lot more common later on.

These psychotic-like symptoms are often put together by health professionals with aggression, wandering, agitation, shouting, hoarding and apathy as well as other ‘behaviours’’ that people with dementia experience. Collectively, these go under the label ‘BPSD’, which means ‘behavioural and psychological symptoms of dementia’. Psychological symptoms also include anxiety and depression alongside the psychotic-like symptoms (delusions, hallucinations, misidentification and paranoid ideas). Misidentification simply means that the person believes someone is a different person.

Studies estimate that somewhere between 50 to 90% of dementia patients will experience at least one of these symptoms at some point and to differing degrees. Those dementia patients with BPSD are much more likely to need residential or nursing home care.

What the studies don’t show is why some people with dementia don’t have psychotic-like experiences and symptoms when others do. It is believed that changes in the person’s brain as a result of the dementia are responsible for the symptoms. Studies on donated brains are underway that will help to understand what causes psychosis in dementia patients. Some believe it is linked to the brain chemical dopamine. Researches believe that dopamine has an underlying role in the psychosis experienced by schizophrenia or other people with mental illnesses.

Alzheimer’s disease

The most prolific dementia cause is Alzheimer’s disease. Research has shown that up to 60% of those with dementia experience delusional thinking and/or hallucinations at some point. A research team reviewed 55 Alzheimer’s studies that took place between 1990 and 2003. In total, 9,749 people took part in the different studies and among them, 36% of people had experienced delusions. Furthermore, 18% had hallucinations. These symptoms were present over several months. Also, around 39% of Alzheimer’s patients reported symptoms similar to psychosis. The most common was ‘misidentification’ whereby a person is identified erroneously as someone else. This is a type of delusion.

Researchers do think that genes have a role to play in the development of psychotic-like symptoms with Alzheimer’s disease although it is unclear which genes play a role.

Dementia with Lewy bodies

Another type of dementia, called dementia with Lewy bodies (DLB) often comes with very vivid and intense hallucinations. People with DLB will frequently see animals, people or children. One typical hallucination is an adult or a child appearing to come through a wall. The name Dementia with Lewy bodies comes from a build-up of particular proteins, Lewy bodies, in the brain’s nerve cells. We find these buildups in people’s brains when they have DLB or Parkinson’s disease and they are named Lewy bodies because of the neurologist responsible for their discovery.

People who have Parkinson’s disease might also have a similar type of dementia. Parkinson’s disease dementia and Dementia with Lewy bodies account for 10 to 15% of all dementia cases. Scientists don’t know the reasons for the existence of Lewy bodies or how the damage they cause contributes to the symptoms of dementia. People suffering from DLB can have very bad reactions to antipsychotic medicines and such medicine can even lead to sudden death in DLB patients.

Common hallucinations and delusions experienced by people with dementia

Those with dementia are much more likely to experience visual hallucinations – that is they see things or people – rather than hear voices. Although different types of hallucinations aren’t as common, it is possible to hear voices and smell, taste or feel things that aren’t there.

One common type of delusion is ‘misidentification’. Many end up believing that their child, partner or spouse is an imposter even.

It is common for people to think that there is someone breaking into their house and stealing their things, many also believe that they are not in their own home or that somebody is attempting to take their home from them. It’s also possible for them to believe that they are a victim of persecution or that people they know who have died are actually still alive.

For older people that have dementia, any kind of delusion is frightening and distressing, whether that is thinking they’re being burgled or believing that their home is being repossessed, for example.

The delusions and hallucinations, however, are not always distressing for the person with dementia but they are quite upsetting for their family members who are caring for and supporting them, in particular, if the delusions involve misidentifying members of their family.

Treatment – antipsychotic medication

In terms of treatments, doctors will not always make a differentiation between ‘psychological’ and ‘behavioural’ symptoms of dementia (BPSD). Hallucinations and delusions are often treated in the same way as behavioural symptoms like shouting, agitation and wandering. In the past antipsychotics have been used to treat delusions and hallucinations. They are powerful medications that ease these symptoms and they also have a sedating effect. Back in 2009, a professor of mental health and ageing based at the Institute of Psychiatry, Psychology & Neuroscience at King’s College London, Professor Sube Banerjee, wrote a government-commissioned report that highlighted the overuse of antipsychotic drugs.

The report, entitled The use of antipsychotic medication for people with dementia: time for action, stated that antipsychotics were frequently prescribed for substantial periods and were beneficial only in a small number of cases. What’s more, there are serious side effects to these drugs including falls, unsteadiness and a greater risk of a serious stroke, as well as unnecessary deaths. The report recommended the prescription of antipsychotic drugs to be only given for those who really needed it. He believed that around 2/3 of these prescriptions weren’t appropriate and that those who have BPSD

Ever since, the NHS and the government have encouraged a huge reduction in antipsychotic used for the elderly with dementia.

In 2012, there was an audit published by the Health and Social Care Information Centre which stated that there was a 52% reduction in prescriptions for antipsychotic drugs for dementia sufferers in England between 2008 and 2011. However, the audit did find that some areas were prescribing antipsychotics at a rate six times higher than other areas in the country.

Research has also found a decline in the number of antipsychotic prescriptions written for people with dementia. One study published in 2012, showed that some dementia sufferers were still being given antipsychotic drugs unnecessarily. People with dementia living in residential care were almost three and a half times more likely to have antipsychotics than those remaining in their own homes. This research was collected from 59 different GP practices in the south of England.

There is only one antipsychotic drug that is approved for use for dementia: risperidone. In 2008, this drug was licenced to treat persistent aggression in patients with moderate and severe Alzheimer’s disease (for up to six weeks at a low dose). It is still possible, however, for doctors to prescribe other antipsychotics if they do so ‘off-licence’, for example, if they think there is a good enough reason to use a certain drug. There is very limited evidence about how effective other antipsychotic drugs are.

If a doctor prescribes an antipsychotic, he or she should discuss the benefits as well as the risks with the patient and their family and should explain why the drugs are being prescribed and mention alternative possible treatments. Antipsychotics need to be prescribed at a dose that is the lowest possible and for a time that is short. The person taking the antipsychotic drugs needs to be monitored to check for dangerous side effects. Since both the psychological and behavioural symptoms come and go, a person with dementia might only be prescribed short courses of antipsychotic drugs on different occasions as necessary.

Other medication

There has also been research to test other types of drugs to see if they can alleviate behavioural and psychological symptoms of dementia. Although antidepressants have been tested to help treat psychotic-like symptoms and agitation in dementia, recent evidence does suggest that these are not very effective.

One research study from 2011 found that painkillers might have benefits to people with dementia that experience agitation. There is a theory that some behavioural symptoms of dementia, e.g. agitation, are actually caused by pain. Pain is difficult to treat in dementia patients because it is not easy to diagnose and people are not always able to describe how they are feeling or what they are experiencing.

Around the world, researchers are investigating other medicines, including medicine that is used to treat high blood pressure, traditional Chinese and Japanese herbal remedies and mood stabilisers.

Other ways of supporting someone with dementia who experiences delusions and hallucinations

The Dementia Action Alliance, a group of 400 plus organisations like Age UK, the Alzheimer’s Society and the Department of Health, recommends ensuring a person with dementia has time with other people and takes part in and tries activities and new activities.

Some authorities for health and social care (as well as some individual dementia care homes) are beginning to introduce training for their support staff in order to help them care for those experiencing delusions and hallucinations as well as other symptoms that come under the BPSD label, all without using drugs. These strategies include distracting the patient, reassuring them, having regular routines, keeping patients active with interesting activities, helping to keep them calm and relaxed and avoiding situations known to trigger symptoms.

Some teams of researchers have been exploring the possibility of training volunteers in the care and support of care home residents with dementia as well as alternative treatments like music therapy. In lots of cases, psychological and behavioural symptoms of dementia will improve on their own in the space of a few weeks.

Who will decide about treatment?

A doctor might refer a dementia patient to a specialist memory clinic for diagnosis and assessment. This occurs either when a person first becomes unwell or when they develop psychological and behavioural symptoms. Specialist teams include old age psychiatrists and specialist dementia nurses.

Dementia specialists are also able to advise a person’s family and caregivers on the best way to manage delusions and hallucinations and offer the individual support if their symptoms are distressing.

Late-life schizophrenia

Despite the fact that most people will develop schizophrenia in early adulthood or late adolescent, it is still possible for some people to develop a similar condition when they are older or middle-aged. These illnesses are referred to as ‘late-onset schizophrenia’ (this is if the illness appears after age 40) or ‘very late-onset schizophrenia-like psychosis’ (if the illness appears after age 60).

A team of researchers estimated that somewhere between 17 to 24 people in 100,000 over the age of 60 have very later-onset schizophrenia-like psychosis. Another research group estimated that somewhere between 0.1 to 0.5% of those over 65 will have schizophrenia and amongst them, 1.5% will have developed the condition after they turned 60. It is more common for women to develop schizophrenia in their advanced years compared with men.

Older people with a schizophrenia diagnosis are given the same treatment as those who have the illness and are younger – talking therapies and antipsychotic medication. Antipsychotic drugs are prescribed in smaller doses for older people but there has not been a lot of research regarding very late onset schizophrenia-like psychosis for psychiatrists and mental health professionals to know how to treat it for the best.

There is no known reason why older people sometimes develop schizophrenia but theories exist surrounding stressful events in later life such as retirement or bereavement, for example, that might contribute.