Caring for a loved one with Alzheimer’s can bring challenges you may not have expected, like your family member seeing or hearing things that aren’t real, conversing with an empty chair, or accusing loved ones of stealing things. These symptoms can be signs of dementia-related psychosis. They can cause fear, agitation, and frustration — for both the person with Alzheimer’s and their caregivers.

Although Alzheimer’s has no cure, treatments can help manage symptoms of Alzheimer’s psychosis. This article covers medications, nondrug approaches, and ongoing research. Understanding these options can help caregivers make informed choices and provide better care.

Understanding Alzheimer’s Psychosis

Depending on the type of dementia and how far it has progressed, dementia-related psychosis can occur in about 20 percent to 70 percent of people with dementia. In Alzheimer’s disease, psychotic symptoms are most common in the late stages, but they can happen early on, too.

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Medication options and possible side effects

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Triggers and how to identify them

Clinical trials and emerging treatments

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Symptoms of Alzheimer’s Psychosis

Dementia-related psychotic symptoms include hallucinations (seeing or hearing things that aren’t real) and delusions (firmly held false beliefs). A person may think someone is stealing from them, believe they are in danger, or see people or objects that aren’t there.

These experiences can be frightening and confusing. Other behavioral symptoms that may occur with Alzheimer’s include aggression and agitation. Other symptoms may include:

People with Alzheimer’s may also experience “sundowning.” This is a period of confusion and agitation that happens in the late afternoon and evening. During this time, people may feel anxious or restless or have more trouble recognizing places and people.

While the exact cause of sundowning is unknown, it may be linked to changes in the brain and the body’s internal clock. Factors like fatigue, dim lighting, unfamiliar surroundings, and stress can make sundowning worse.

Causes of Alzheimer’s Psychosis

Alzheimer’s-related changes in the brain may contribute to hallucinations and delusions. The progressive deterioration of brain cells is a major cause of behavioral symptoms in Alzheimer’s, but hallucinations and delusions can also have other causes.

Other causes of hallucinations or delusions may include:

Delirium can also cause hallucinations or delusions. Delirium is a sudden change in a person’s mental state that can affect attention, awareness, and thinking. It’s more common in people with dementia.

Because these problems can cause or worsen hallucinations or delusions, new or worsening symptoms should be evaluated by a healthcare professional.

Nondrug Approaches for Alzheimer’s Psychosis

Hallucinations and delusions in Alzheimer’s can also be managed with nondrug approaches that focus on comfort, safety, reducing triggers, and improving quality of life. Caregivers may need to try different strategies to find what works best.

Look for Triggers and Unmet Needs

A change in behavior may be a clue that something in the person’s surroundings or routine is bothering them. Changes in caregivers or surroundings (such as moving to a nursing home or unfamiliar place), fatigue, and discomfort may contribute to behavioral symptoms.

Checking for pain, hunger, thirst, constipation, a full bladder, or signs of illness may help identify needs the person can’t easily communicate.

It can also help to notice when and where hallucinations or delusions occur. For example, do they tend to happen in a particular room, at a certain time of day, or after a change in routine? Keeping track of patterns in a simple log may help caregivers identify possible triggers and make changes.

Respond Without Arguing

Trying to convince someone that a hallucination or delusion isn’t real may increase frustration. Instead, avoid arguing about what the person sees, hears, or believes. Focus on the emotion behind the experience and offer reassurance if they seem frightened or upset.

Redirection may also help. You might suggest moving to another room, taking a walk, looking through photographs, or listening to familiar music. If the person says they see something that you don’t, you can acknowledge that they’re experiencing something without agreeing that it’s actually there. The goal is to help them feel safe rather than prove what’s real.

Create a Calmer Environment

Small changes to the surroundings may make hallucinations or delusions less upsetting. Reducing noise, glare, and background distractions can help create a calmer setting. Good lighting may also reduce shadows or objects that could be misinterpreted.

Pay attention to what the person is seeing and hearing. A TV show or mirror reflection may seem real and cause distress. Turning off the TV, improving lighting, or covering mirrors may help. Familiar routines and calming activities can also make the person feel safer.

Emerging Treatments and Clinical Trials

Researchers are studying new treatment options for Alzheimer’s psychosis. KarXT is being tested in a phase 3 trial in adults with Alzheimer’s disease and moderate to severe psychosis. It is approved for schizophrenia but not for Alzheimer’s psychosis.

Researchers are also studying noninvasive brain stimulation, such as repetitive transcranial magnetic stimulation (rTMS), for dementia-related symptoms. One published report involving a person with Alzheimer’s described improvement in some cognitive and behavioral symptoms, but rTMS is still experimental for Alzheimer’s psychosis.

People interested in clinical trials can ask their healthcare team whether a study may be appropriate for them.