Dementia is often associated with loss of memory or misplacement of things. However, sometimes dementia manifests in different ways. Paranoia is one of the ways that dementia can manifest; the person suffering from dementia becomes suspicious to the extent of doubting everything and everyone. The connection between paranoia and dementia is something that affects many families in the world. It is painful and confusing for families with a loved one suffering from dementia and paranoia. This is because the dementia patient becomes so preoccupied with their thoughts that they end up doubting everyone around them.

What does paranoia look like in dementia?

Paranoia in dementia does not manifest like the movies. In most cases, it starts as mild and progresses to crankiness. The dementia patient has paranoid thoughts that lead to them:

• Thinking that family members are stealing from them
• Believing that their neighbors are spying on them or conspiring against them
• Accusing caregivers of hitting them
• Believing that other people are talking about them behind their backs
• Insisting that someone is entering their house without permission
• Believing that someone is poisoning their food

These thoughts are 100% real to them. They are not trying to piss them off or drive them mad with anger and frustration. It is just their brain's way of processing information.

How does the brain affect this?

The changes in the brain that come with dementia affect the way people perceive information and think. Some of the causes of paranoid thoughts include:

• Memory loss, which can lead to confusion: When someone gets lost and can't remember things easily, they may believe someone has taken them away.
• Vision and hearing problems: These can be so severe that even familiar people seem like strangers to the patient until someone comes and says they're visiting.
• Thinking problems: The brain can't figure out whether fears are real or not.
• Sensory changes: When vision changes, and hearing becomes difficult, soft music may seem scary, and shadows may seem frightening.
• Loss of habitual activities: Difficult and sudden situations slow down the brain's processing and may lead to paranoid explanations to help understand the whole picture.
• Health problems: Paranoia can sometimes be exacerbated by underlying health problems, such as infections, certain medications, or lack of sleep, which can further exacerbate these feelings.

Impact on families

Paranoia does not just affect the dementia patient but the entire family. Grown-up children feel abandoned when their parents accuse them of theft or lying, even after they had a close relationship. Family and friends become frustrated when they realize that they cannot be trusted. Family members feel:

• Depressed because of the accusations and mistrust
• Tired of having to repeat themselves over and over again
• Concerned about the well-being and safety of their loved one
• Feeling isolated 
• Perplexed about how to respond or what to do

In most cases, the patient's brain is trying to make sense of the confusing world, and paranoid thoughts make perfect sense. The fear is overwhelming, even if they know that others do not see things as they do. 

Additionally, different forms of dementia may cause paranoia in different ways: 

• In Alzheimer's disease, the patient experiences memory loss and recurring suspicious thoughts. 
• In frontotemporal dementia, personality and behavior changes occur early. 
• In Lewy body dementia, visual hallucinations may increase along with paranoid feelings.

Let’s understand this with an example. Maria, a 62-year-old, thought someone was spying on her and following her. She kept complaining that people were following her even to the market, and she believed in her delusion so much that she wouldn’t stop talking about it. She was initially misdiagnosed as having mild cognitive impairment because she had good memory and could engage in a meaningful conversation. However, after doing further tests, including a brain imaging test, she was found to have frontotemporal dementia paranoia. It is the reason why, even though her memory was still intact, she was having paranoid thoughts. 

How can professionals make a difference?

A mental health professional, like a board-certified geriatric psychiatrist, uses several aids to help better understand the problem: 

• They interview the patient and the family. Family members are usually the first to recognize some behavioral changes in a person that they have not noticed themselves. 
• Cognitive tests are done to assess the functioning of different parts of a person’s brain. These tests assess memory, attention, language, and problem-solving ability. 
• A brain scan that shows pathological changes in the brain areas.
• Blood tests to rule out any anemia or illnesses that may present with similar symptoms, such as vitamin B12 deficiency or hypothyroidism. 

After making a thorough diagnosis, they develop a personalized treatment plan which includes:

• Medications to help with the paranoia and anxiety. (In the example given above, Maria was first given medications that helped manage her paranoid thoughts.)
• Psychotherapy, a form of therapy that benefits the person with dementia and their family, as they can learn how to cope. (The psychiatrist also taught Maria’s family how to make her feel less threatened and secure.)
• Environmental changes, such as creating a quiet environment. The less noise, the better, as noise can trigger confusion and suspicious thoughts.

If you find it difficult to visit their clinic in person or you want to have a consultation from the comfort of your home, then meeting a geriatric psychiatrist online or a neurologist near me can be a good option. Note that an online psychiatrist can only prescribe medication that is licensed in the state you live in. For example, if you live in New Jersey, an online psychiatrist New Jersey can prescribe medication.

Practical tips for everyday living

Paranoia in a person with dementia is challenging, and the caregiver needs to be patient and creative. Some strategies that may help include:

• Be affirmative: You can try saying things like ‘‘these are really frightening thoughts’’ or ‘‘I can see this is really tough for you’’, without arguing.
• Don’t change routine: An irregular daily routine can be disrupted, in which case planning becomes difficult, and solution-finding becomes clouded by confusion.
• Minimize stimuli: For instance, if paranoia worsens when watching a particular television show, it might be better to change the channel to a better alternative. (In Maria's case, her daughter encouraged her mother to engage more in other hobbies and positive things that she loved, like flipping through old albums and listening to her favorite old music. They were very fulfilling experiences that counteracted the negative ones.)
• Follow-up and Support: Regular follow-up visits with a psychiatrist help keep the family updated about the treatment response, environmental modifications, and their participation in patient care.

Remember that the key to treatment is not to cure dementia, but to make the individual with dementia feel more comfortable and secure. This often depends on how quickly the person feels less afraid after the paranoia subsides, and as a result, they can eat and sleep better than before.

As previously mentioned, this condition of dementia and paranoia does not just affect the patient, but the entire family. Children, spouses, and other loved ones may feel sad, distressed, or helpless. Finding comfort through therapy with a psychiatrist or having similar support from someone in a group setting provides you with opportunities to get advice about how others are dealing with or using certain coping skills for the same issues. Remember that taking care of yourself by receiving emotional support is not selfish; it is necessary.