October 2025 Hallucinations Paranoia Delusions and Sundowning
Navigating challenging interactions
(Hallucinations/Delusions/Paranoia or confusion during periods of “sundowning”)
To navigate challenging interactions such as during hallucinations, delusions and paranoia, and confusion during periods of “sundowning” it is important to validate what the person is experiencing.
- Do not deny their reality but meet them where they are at now.
- Be sensitive to the specific journey the person is on, especially for the Violet, Rose and Bouquet Journey, the correct approach is essential (see approach for each Memory Bouquet Journey.)
- Keep in mind that someone on the Violet, Rose or Bouquet Journey is likely to mirror the emotional state of their care partner or immediate environment and space. (be sensitive to the message it is sending)
- Do remember that you are the anchor for them in their current reality. It is up to you to offer a positive sensory experience to replace the current negative state of mind.
What is sundowning in dementia:
- Increased restlessness and confusion towards the end of the day and evening time
- It is a set of symptoms/behaviors that are magnified at the end of the day (anxiety/hallucinations/agitation/pacing/disorientation)
How to navigate sundowning:
- Try to capture the specific signs and symptoms of your loved one and possible triggers
- Routine, routine, routine is the secret to helping your person feel secure and in control
- Create a meaningful day with a strong day-to-night scheduled routine: the same thing happening at the same time in the same way (for example mealtimes/dressing for daytime and dressing in pj’s/ periods for meaningful activity especially time outside in the sunlight; exercise and movement and music should be included)
- Establish a hydration schedule that starts at breakfast time (hydration is the cornerstone of cognition and alertness)
- Establish a 2-hour toileting schedule to avoid periods of discomfort.
- Create a calm environment after dinnertime. Try a short walk at sunset or directly after the meal and observe the change in the day.
- Create a bedtime routine that may include dimming of lights; aroma therapy; soothing sounds/music; changing in pj’s and rubbing lotion on hands, feet and back. Consider a book on tape while person gets into bed or calming nature scenes on the TV (if the TV has to be on)
- An evening snack may reduce restlessness during the night
- Consider motion activated night lights
Here are some tips to try introducing a positive experience during episodes of hallucinations, delusions and paranoia:
*Get a UTI test if there is a sudden onset of challenging or changed behaviors- it may be caused by an infection.
- Know the triggers for the person and the type (When, why, what)
- When in doubt: hydrate your person. Dehydration may cause abnormal thinking patterns - keep favorite drinks handy.
- Keep in mind that your person may be bored, or have a need for toileting, or have pain or is lonely or tired or hungry and may not be able to express this to you. (know their habits, for example. Try to track frequency of bowel movements if possible, and allow for routine naps and routine snacks)
- The sucking or rooting reflex is a powerful way to calm the nervous system immediately (try lollipops; mints; drinking a cold sweet drink through a straw; popsicles) Especially helpful for a person with Lewy Bodies Dementia (LBD).
- Cold temperatures (drinks/ice-cream/popsicles) will anchor person in the here and now.
- 4 Squared breathing: inhale for 4 counts; hold 4 counts; exhale for 4 counts and hold 4 counts DO 4x (calms down the nervous system and fight/flight response)
- Deep therapeutic touch such as massaging hands/feet/extremities with lotion may be helpful for tactile hallucinations (to relief excessive itching or the feeling of bugs under the skin; consider pressure garments to assist with circulation)
- Music of their choice will calm the nervous system.
- Pictures/videos: Try funny topics: children; animals or family or friends to engage in humor which releases endorphins and can help with mood.
- A weighted blanket over the shoulders or on the lap may be helpful to calm someone.
- Sharing a salt or sweet snack may be helpful
- Nature videos or sounds or just going outside to sit or walk and observe the breeze, sun on our skin, sights and sounds while sipping a cold drink is a great tip.
- Keeping a strict routine and schedule may help anchor your person in what is happening next in their day – keep it on a white board in line of sight and with easy access.
- Sitting in a rocking chair can also calm the nervous system.
- For LBD: (Lewy Bodies Dementia)
Create a written recipe of strategies for your person to try when they experience hallucinations and/or delusions/paranoia - keep items ready in a basket or marked clearly in the fridge or on the countertop or bedside table especially for nighttime challenges. Keep several copies of the individualized recipe where your person can see it: by their chair; next to the bed; on the refrigerator; by their medication box.
For example:
" When you experience upsetting thoughts; sounds or voices or even seeing strange things, it is your brain needing some therapy. Drink a cup of cold water and set the TV to the nature channel number 3 - these thoughts and images or voices will soon stop. Please call or ask for help if you feel frightened. (provide a name and number)"
