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Visual Hallucinations and Paranoid Delusions  -   R. C. Hamdy, MD, A. Kinser, PhD, Tracey Kendall-Wilson, RN, ...
First Published May 30, 2018 Research Article https://doi.org/10.1177/2333721418777086

Abstract
Visual well-formed hallucinations, fluctuations in the level of cognition, and alertness and extrapyramidal signs are core features of dementia with Lewy bodies. Some patients realize that what they are seeing or hearing are just hallucinations and learn to accept them. Others, however experience these hallucinations as quite real and cannot be dissuaded from the firm belief that they are. In fact, efforts to dissuade them often serve only to confirm the often associated paranoid delusions and this may lead to a catastrophic ending. Hence, it is best not to contradict the patient. Instead, attempts should be made to distract the patient and change the focus of her or his attention. In this case scenario, we present a 68-year-old man who has been diagnosed with dementia with Lewy bodies. He lives with his daughter. He has visual hallucinations and paranoid delusions that worsen at night: He thinks there are people outside the house plotting to kill him. We discuss what went wrong in the patient/caregiver interaction and how the catastrophic ending could have been avoided or averted.
Keywords Alzheimer’s/dementia, caregiving and management, cognition, confusional states
Objectives
At the end of the scenario readers will appreciate the following:

Visual, well-formed hallucinations are core features of dementia with Lewy bodies (DLB). Patients also can have paranoid delusions.
It is best not to contradict a patient who has hallucinations and is delusional. To the patient, these are real.
If rationalizing with the patient is not successful the first-time round, further rationalizing should be avoided.
It may be helpful to play along with the patient until such a time that she or he can be distracted.
Disabling accessible guns at home may be a better strategy than hiding them.
Case Presentation
Characters
Edwin, 68 years old, has DLB. His wife died about a year ago.
Rosa is Edwin’s daughter. She is a widow and lives with her father.
Rosa and her father are planning to visit her son, Raymond, and his family the following day, about 150 miles away.
Scenario
It is about 9:00 p.m., Edwin and his daughter Rosa have spent the past hour watching the news and commentaries on TV. Rosa stands up and tells Edwin that it is time to go to bed, reminding him that the following day they will be driving to visit Raymond and his family and that it will take them about 3 hr to get there.

Rosa is thinking about the long day they have ahead and the chores she still has to do to make ready for the trip. She notices that her father is anxious and agitated. He utters in a very hesitant voice:

Rosa, I saw and heard them outside my bedroom window. I heard them say that they are going to kill me. I don’t want to go to bed . . . and I don’t want to go to my room.
He is trembling, shaking and looks afraid.

Rosa first tries to reassure him that they are safe and secure, that nobody is outside the house and nobody is trying to kill him. They live in a safe, gated community; no outsider can get on the premises. Edwin is not convinced. Rosa then offers to go to her dad’s bedroom and check the window. Edwin refuses, “Please, don’t leave me alone. I saw them. They’re coming. I know. Please don’t go.”

Rosa tries to explain that the trees outside, the rain falling, the wind rustling the leaves, and the moon shining through the clouds are playing tricks on him and making him believe there are people with bad intentions outside. But Edwin does not accept it. “I saw them and heard them. They have evil intentions. They want to kill me.” Again Rosa tries to convince him, but to no avail.

Rosa again and again tells her dad that he is just imagining things. She reminds him they live in a very secure gated community and have nothing to worry about. But Edwin refuses to accept this. Rosa then reminds him that the doctor they saw a few weeks ago said that he may have hallucinations and that they should not worry about it. “Rosa! I’m telling you, I could see and hear them as clearly as I see and hear you now. They want to kill me!” Rosa tries to reassure him but he is not dissuaded. Edwin grows increasingly agitated. Rosa is tired and still has chores to do before going to bed; she is losing both patience and strength. Edwin lies down on the sofa and states that he will spend the night there.

Taking Edwin by the arm and pulling him up, Rosa tells him that he is being silly and implores him to go to his room. Edwin is upset. He now thinks that his daughter is in cahoots with the murderers outside his window. “My own daughter, my own flesh and blood. Get away from me before I hurt you! I’ll take care of the people outside myself. I’ll kill them all, same as I did many times in Nam” He opens the drawer where he used to keep his gun and rummages through the drawer but cannot find the gun. He demands that Rosa tell him what she has done with the gun. Rose tries to explain that the doctor told her to hide it so that he does not injure himself.

Edwin is angry now; he curses the doctors and yells about them “meddling in other peoples’ affairs.” He picks up the car keys and announces that he is going to the gun fair, about 30 miles away, to get a gun; he says he may even get two or three guns. “I don’t even have to wait for security clearance. I’ll pay cash and buy the guns.” He pulls a few 100 dollar bills from another drawer and storms out of the house. Rosa tries to physically stop him, but he pushes her away; she falls on the ground, injured, and cannot get up. Edwin drives off.
Case Analysis
Turning Points—What Went Wrong? Could It Have Been Avoided, Averted, or Defused?
Rosa cavalierly dismisses her dad’s fears
Rosa just tells her dad that he is imagining things and that nobody is outside the house trying to kill him, but does not verify it. In other words, she contradicts him without first ensuring she is correct and that her dad is having hallucinations and is delusional. Edwin may therefore feel that his daughter does not really believe him: if she had, she would have made attempts to find out whether the threat is real or imaginary.

Edwin firmly believes that there are people outside the house planning to kill him. He categorically states that he saw them. Trying to convince him of the contrary is likely to be a difficult almost impossible task especially after the first few attempts at trying to convince him were not successful. The more his daughter tries to convince him that he is hallucinating and has delusions, the more entrenched Edwin tends to become in his belief that they are real. In other words, it does not help to repeatedly try to convince the patient of these hallucinations and delusions, especially if the patient is agitated and anxious.

It would have been more convincing to Edwin that he is hallucinating had his daughter attempted to find out if anybody was outside the house. Instead, she just tells him that these are hallucinations and reminds him of their encounter with his doctor who warned him about having them. Contradicting her dad creates conflict between patient and caregiver.
Could
it have been averted/avoided?

Rather than repeatedly trying to convince him that that he is having hallucinations and delusions, his daughter should have tried to distract him and get him to refocus his attention on some other object or activity. However, for this strategy to be successful, the caregiver should not persist in trying to convince the patient that he is hallucinating because with each failed attempt it becomes more and more difficult to convince the patient that he is hallucinating and having delusions.

Edwin would have been much more likely to accept that he is hallucinating had his daughter entertained, or pretended to entertain his hallucinations, albeit temporarily. For example, she might have taken the following steps:

Peered through the windows to see if someone was outside the house.
Switched on the lights outside the house to have a better view of the immediate surroundings of the house.
Thoroughly and convincingly checked and demonstrated to her father, that the windows and doors are properly closed and the security system is armed.
Once reassured, she could have gone outside, with or without her dad, to further convince him that no one is lurking outside. On the way out, she could have picked up a disabled gun to further demonstrate to her dad that she believes him.
Told her dad that she is going to phone the police, ask him to accompany her, making sure he is hearing her “talk” to the police, while in fact only pretending to do so.
After using such strategies, she may then try to distract her father. For instance, as they go through the kitchen she may offer him a drink or his favorite food. Similarly, as they go through a bedroom she may ask him to check an electric outlet or drawer that does not close properly. This has the added advantage of Edwin’s feeling needed and may distract him from his original delusions.

Rosa, therefore, needed to distract her dad or get him to focus on a different issue very early in the evening as soon as she became aware of the hallucinations. She may, for instance, have asked his help to load the car, or put out the clothes he will be taking with him on their forthcoming trip.
Rosa tries to argue with her dad, providing rational explanations to his hallucinations and delusions
The more Rosa tries to argue with her dad and convince him that he is hallucinating the more likely is her dad to get entrenched into his hallucinations and delusions, especially as he is anxious, apprehensive, and agitated. Given his condition it is very difficult for him, especially at this stage, to make the correct associations and be convinced that the voices he heard were the wind rustling through the leaves of the trees and that the shadows he saw were the moonlit surroundings of the house and the cloudy sky.

Although these are logical arguments, a patient with dementia is unable to make the required deductions and be convinced that his hallucinations are not factual. Edwin’s judgment is impaired. He is not in a position to understand the seemingly convoluted argument his daughter is making. To accept this argument, he would have to be able to detach himself from his beliefs and recognize the rationality of the argument. Given that he has dementia and therefore an impaired judgment, he cannot do this.
Could it have been avoided?
Arguments should be avoided It is very difficult, almost impossible, to convince a patient with dementia of logical arguments because the patient is unable to draw the expected conclusions. In addition to the poor memory and the short attention span, patients with dementia have an impaired judgment.