Hallucinations, Delusions and Paranoia

Specific strategies to manage hallucinations, delusions & paranoia.

The following scenario describes the recommended approach and responses to preventing and managing hallucinations, delusions and paranoia. Below the flow chart you will find specific strategies to manage hallucinations, delusions and paranoia.



Sensory experiences that can’t be verified by anyone other than the person experiencing them. Any sense may be involved, but seeing or hearing things is the most common.

Example: Staff ask Mrs Z how she slept last night. Mrs Z replies that she didn’t sleep well at all as there are numerous bugs that reside in her bed & attack her at night. She takes the staff to her room, pulls back the bed covers & says “See them crawling?” The staff couldn’t see any bugs. Hallucinations are often a symptom of delirium and it is very important to assess any person presenting with hallucinations for delirium (Please refer to the Confusion Assessment Method page).


False, fixed beliefs that are not in keeping with the person’s background. Delusions remain fixed or persistent despite all evidence to the contrary.

Example: Mrs Y refuses to eat her meals because she believes that her food is poisoned. She sees the food being dished up & everyone else having the same food but still believes that hers is poisoned.


Unrealistic, blaming beliefs. A person with paranoia will not accept explanations of the unreality of their beliefs.

Example: Mr Y believes that staff only wear red jumpers when they intend to hurt him and cannot be convinced otherwise, despite all the evidence and explanations put to him.

Paranoia can result from damage to the part of the brain that makes judgements & separates fact from fiction. This paranoia is common in people with dementia.

Example: Mrs X can’t find the $50 she hid under her pillow. She has forgotten that she took the money out from under the pillow yesterday & hid it under a stack of magazines in her wardrobe. Mrs X accuses the staff of taking her money. When the money is found (in Mrs X presence) she believes the staff have replaced it because she kicked up a fuss.

Confused people often misinterpret their circumstances or surroundings due to a diminished state of awareness and a reduced ability to understand what is happening to them. Confusion is often misinterpreted as delusional or described as paranoid despite the person accepting the explanation given to them.

Example: Mr W has dementia and believes his family has abandoned him. He feels angry and distressed. Staff take the time to sit with him and discuss his feelings. They draw his attention to cards and photographs on his bed-side table that are from his family. Mr W is reassured.

Try these approaches for misplaced objects:

  • Remind the person where valuables are stored for safe-keeping. Provide small amounts of money to persons accustomed to having money on their person.
  • A message displayed on the wall stating that staff have the valuables in the safe may help to reorient and reassure the person.
  • Look for, or assist in looking for, lost articles.
  • Do not scold them for losing items or hiding things.
  • If possible, keep a spare set of items that are frequently misplaced such as purse, glasses etc.
  • Learn where the person’s favourite ‘hiding places’ are & let other staff know.

Nursing interventions

  • Regular vision and hearing assessments and examination of sensory aids such as glasses and hearing aids. Visual impairment can easily lead to misinterpretation of objects in the environment and diminished hearing can lead to ‘hearing noises’ that are unintelligible, which in turn may be construed as ‘auditory hallucinations’.
  • Assess for illness, infection, chronic pain or bowel impaction.
  • Review medications.
  • Visually inspect the head & face for bruises or grazes from unwitnessed falls, particularly if there is also a sudden change in the person’s level of alertness.
  • Change environment as little as possible.
  • Ensure the environment is well lit but not glary. Shadows and glare can lead to visual illusions.
  • Don’t argue or directly disagree with a false idea. State what you know is true, then try to distract the person, e.g.; “Let’s go for a walk”.
  • Respond to general feelings of loss within a conversation. Specific statements may be “I have to get dinner ready for when father comes home from work”, when their father is dead. The memory of the person (father) may be stronger than the memory of his death. Instead of telling the person that their father is dead, try saying, “You must miss your father”, or “Tell me about your father”.
  • When a person is upset about something that may be missing, discuss their feelings about the lost object. For example: Mr B’s dog died six months ago and he misses the dog desperately. Mr B accuses the staff of hiding the dog. In response the accusation, staff replied, “You really miss the dog don’t you. I bet she was good company. Have you any photos of her you could show me?”
  • Use familiar distractions such as: music, exercise, card playing, reminiscence therapy etc.

Other considerations:

  • Some people are more suspicious than others. The confused person wakes up every day in unfamiliar surroundings. They’ve forgotten their environment and the trusted people in it, so it’s understandable that they may be suspicious.
  • Recording behaviour on a ‘behaviour chart’ will help to identify particular times of day or activities that trigger hallucinations or suspiciousness. If these can be identified it may be possible to alter the routine & avoid such behaviours, or to anticipate problems and be ready with distractions.
  • Hallucinations or false ideas may be harmless & are sometimes best ignored or accepted. If they don’t upset the person experiencing them, there may be no need for intervention. Always report delusions and hallucinations to the person’s doctor to rule out physical or psychiatric illness.
  • Don’t take accusations personally. Remember that personality changes are a result of the dementia & that the person can’t control these behaviours.

References and recommended reading

Alzheimer's Association Australia (2000). Help Sheets for people with dementia and their families and carers. Alzheimer's Association Australia. [available online] http://www.alzheimers.org.au/

Department of Veterans Affairs - Health Promotion Section & Alzheimer's Association Australia (2001). Living with Dementia - A guide for Veterans and their Families. Commonwealth of Australia [available online July 2002] http://www.dva.gov.au

Robinson, A. Spencer, B. & White, L. (1991). Understanding Difficult Behaviours: Some practical suggestions for coping with Alzheimer's Disease and related illnesses. Eastern Michigan University, USA.