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Types and causes of hallucinations in dementia

Key points

  • Hallucinations are false sensory experiences (seeing, hearing, smelling, tasting, or feeling things that are not there) caused by brain damage from dementia.
  • They are most common in Lewy body dementia (80%) and less common in Alzheimer's (13%).
  • Never argue or try to convince them it is not real—validate their feeling and redirect their attention.
  • Always rule out delirium from infection or medication before assuming it is dementia-related.
  • Environmental changes (lighting, reducing shadows, covering mirrors) can reduce triggers.
  • Only treat with medication if hallucinations are distressing or dangerous, and always under a doctor's guidance.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Stay calm and do not argue. Say in a gentle tone: 'I can see you are upset. Tell me what you are seeing. I am here with you.' This validates their experience without agreeing or disagreeing.

  2. Gently redirect their attention to something real and soothing. For example, if they see a stranger in the room, say: 'Let's go look out the window at the birds together' or 'Would you like a cup of tea?'

  3. Check for environmental triggers. Dim lighting, shadows, reflections in mirrors or windows, or patterned wallpaper can be misinterpreted as people or animals. Turn on bright, even lighting and close curtains at night.

  4. Rule out physical causes first. Check for fever, pain, constipation, dehydration, or a urinary tract infection—these can cause delirium that looks like hallucinations. If there is a sudden change, call their doctor.

  5. If the hallucination is not distressing, you may not need to do anything. Many people with Lewy body dementia have benign visual hallucinations (like seeing children playing) and are not bothered by them. Intervening can cause more upset.

  6. For frightening hallucinations, use a calm, reassuring presence. Sit with them, hold their hand, and say: 'I am right here. You are safe.' Avoid saying 'It's not real'—instead, focus on comfort.

  7. Consider using a nightlight or a dim lamp in the bedroom to reduce shadows. A white noise machine can help mask auditory hallucinations like voices or knocking.

  8. If hallucinations are frequent and distressing, keep a diary noting the time of day, what the person was doing, and what they saw or heard. Share this with their doctor to guide treatment decisions.

  9. For auditory hallucinations, try playing familiar, calming music or a favorite TV show at a low volume. This can 'fill the silence' and reduce the brain's tendency to create sounds.

  10. If tactile hallucinations (like crawling skin) are present, gently check their skin for any actual irritation (like a rash or bug bite). A cool washcloth or lotion can provide soothing sensory input.

What not to do

  • Do not argue or try to convince them it is not real. This will only increase their distress and erode trust. Instead, validate their feeling and redirect.

  • Do not play along or pretend you see it too. This can confuse them further. Instead, say: 'I don't see it, but I see that you are upset. Let's focus on what helps you feel safe.'

  • Do not use medication as a first resort. Many hallucinations are not distressing and do not need treatment. Medications can have serious side effects. Always discuss with a doctor first.

  • Do not ignore sudden or severe hallucinations. They could be a sign of delirium from an infection or medication reaction. Seek medical evaluation promptly.

  • Do not leave them alone if they are frightened. Your presence is the most powerful calming tool. Sit quietly with them until the episode passes.

Practical tools

  • The 'Calm Presence' Script

    When your loved one is frightened by a hallucination, use this exact phrase: 'I can see you are scared. I am right here. You are safe with me.' Repeat it slowly and calmly. Do not ask 'What do you see?' as that can prolong the episode. Instead, gently guide them to a different topic or activity.

  • Environmental Checklist

    Print this list and keep it handy: (1) Turn on bright, even lighting to reduce shadows. (2) Close curtains or blinds at dusk. (3) Remove or cover mirrors if they cause confusion. (4) Reduce clutter and patterned wallpaper. (5) Use a nightlight in the bedroom and hallway. (6) Check for reflections in windows or glass.

  • Hallucination Diary

    Keep a small notebook or use a notes app to record: date, time, what the person said they saw/heard/felt, how distressed they were, what you did, and whether it helped. This pattern can help you and their doctor identify triggers and decide if treatment is needed.

  • Soothing Sensory Kit

    Prepare a small box with items that engage the senses in a calming way: a soft blanket or stuffed animal, a lavender sachet, a favorite song playlist, a hand lotion with a mild scent, or a simple puzzle. When a hallucination occurs, offer one of these items to redirect their focus.

  • Nighttime Safety Setup

    For hallucinations that happen at night: use a dim, warm-colored nightlight (avoid blue light). Keep a glass of water and a small snack nearby. Play soft, familiar music or a white noise machine. Ensure the path to the bathroom is clear and well-lit to reduce falls.

  • The 'Redirection' Phrase Bank

    Have these phrases ready: 'Let's go see what's in the kitchen.' 'I could use your help folding these towels.' 'Look at this photo album with me.' 'Would you like to listen to some music?' The goal is to shift their attention without directly confronting the hallucination.

Discuss with your clinician

If hallucinations are new, sudden, or accompanied by confusion, fever, or a change in behavior—this could be delirium from an infection or medication. Call their doctor immediately.

If hallucinations are causing significant distress or danger (e.g., the person tries to 'escape' from a hallucinated threat), ask the doctor about non-drug behavioral strategies first. Medications like antipsychotics have serious risks and should be used only when necessary.

If your loved one has Lewy body dementia, discuss the risks of antipsychotic medications—they can cause severe side effects including parkinsonism, sedation, and even death. Always work with a specialist.

If hallucinations are accompanied by other symptoms like tremors, stiffness, or falls, ask about a referral to a neurologist for a full evaluation.

If you are unsure whether what you are seeing is a hallucination or a delusion, describe the exact behavior to the doctor. They can help differentiate and guide the right approach.

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