Some elderly people may suffer from hallucinations or delusions, without having a history of psychiatry. How is that possible?
On his daily walk with the dog, he (73) sometimes mistakes trees for people. Fortunately, he realizes that it is not right, but it does make him restless and anxious. And it goes from bad to worse, until he also sees people and animals in the house that are not there. Cats, beetles and strangers stalking him at night in his own house. He grows increasingly anxious, his wife notices, and eventually he becomes so confused that he is forced into a mental health facility.
Everything points to a psychotic disorder in this patient, but that is an illusion, says Evelien Lemstra. She is a neurologist at Alzheimer Center Amsterdam and came across this case. Hallucinations are all too often a symptom of dementia. And that of ‘Lewy body dementia’ (LBD). After Alzheimer’s disease, this is the most common variant of dementia, says Lemstra, although it is little known among the general public.
Shame
“It affects 5 to 10 percent of all people with dementia. That is probably an underestimate, if you consider how often the diagnosis is only established for the first time after death.”
Research by Lemstra shows that the hallucinations occur more often than expected, but that patients do not bring it up out of shame. “Even though it’s usually mild visual hallucinations, or ‘illusionary fakes’ like seeing a face in a foliage or flying insects.”
Tip for loved ones: do not enter into a discussion about whether the observations really exist. Lemstra: “It is better to reassure your partner and try to distract yourself. Also make sure you have good lighting, because hallucinations often arise when it starts to get dark. They also become attached to specific objects. I know someone who kept seeing a sphinx in a toilet bowl.”
It is striking that patients hardly suffer from a faltering memory. In addition to hallucinations, they do report Parkinson’s-like complaints such as stiffness, slow movement, but also attention problems and strong changes between alertness and confusion.
Wrong medication
Like all forms of dementia, LBD is caused by protein accumulations in brain cells, causing those brain cells to die. In this case, the cells encapsulate the protein clumps, creating a kind of balls that Lewy bodies are named after neurologist Friedrich Lewy, who first described them in 1912.
There is no cure for the time being, but the treatment of symptoms is. Although this has to be done very carefully, says Lemstra. “Because in half of the patients, medication initially turns out wrong. Anyone who ends up in a crisis situation with hallucinations, for example, will soon be given the antipsychotic haldol, but that is out of the question. This makes patients drowsy and stiff. They are sensitive to many drugs, and that is probably because multiple brain circuits are involved in this condition.”
The question on which many researchers are now concerned is how to recognize the disease at an early stage. A starting point may be that many patients have a REM sleep disorder for years before the diagnosis. “That means that during the dream phase the muscle tension, which normally disappears, remains intact. And then you get that during a dream you start moving, screaming or hitting around you. Something that, incidentally, affects spouses more than the patients themselves.”