The Emergence of Suspicious Behavior in People With Dementia

Published on March 14, 2023 .

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Stage dementia suspicious — Image by Ground Picture via Shutterstock

Each stage of dementia presents various challenges, and there is no hard and fast rule regarding when certain behaviors emerge. When your loved one has suspicious behavior, managing it can often be challenging. The person with dementia does not possess the insight to realize their suspicion may not be realistic. The certainty that their false belief is true can be rather distressing for them. It is equally upsetting for you as their loved one, who is often the target of that suspicion.

Delusions that may cause suspicious behavior most often occur in the later stages of dementia but may also occur at any stage of the disease.
Investigating the cause of suspicious behavior by your healthcare provider is needed in case the behavior is from a treatable cause, such as delirium due to an infection.
Non-pharmacological or non-drug strategies are the first line of treatment for suspicious behaviors. Your healthcare provider should only consider medications if the behavior or delusions are causing extreme fear and distress.

With our aging population, the rate of people diagnosed with dementia is rising exponentially, with the risk of dementia doubling every five years after age 65. Experts predict that by 2050, 153 million people will live with dementia if the current trend continues. While research into new treatments is ongoing, education about all aspects of the disease is paramount to care for this vulnerable population. In addition, an accurate assessment, treatment, and strategies to manage care will help families to cope with each stage of the disease.

The real-life story of suspicions & dementia

Martha has Alzheimer's and lives in a retirement home. Martha truly believed her retirement home staff was stealing from her. She sat across from her care manager and described the lost items. She was missing her watering can for her plants and "just knew" the support worker "lifted it." She also told the care manager that a shampoo bottle was not in her bathroom, and she knew the dietary aid had "shifty eyes." Martha was sure she was "eyeing it up" when she delivered the snacks yesterday. The care manager listened to Martha and validated her feelings. After all, there is always the chance someone has stolen a person's items, but things are often merely misplaced, replenished, or intentionally stored in a new location.

Suspicious behavior in dementia

When learning about suspicious behavior in dementia, you may see three terms used interchangeably, including delusions, paranoia, and suspicions. All three words have similar features but are also somewhat different:

Delusion. A delusion is a firmly held false belief that something is true when all evidence demonstrates it is false. Changes in brain function cause delusions and may be symptoms of certain mental health disorders, stroke, drugs, brain tumors, dementia, or delirium.
Paranoia. It is an unrealistic distrust of other people, often due to delusional thinking. A person with paranoia may have intense doubt and fear.
Suspicion. This type of behavior often accompanies paranoia as it is the action someone takes who has an unrealistic distrust. Since this person may be fearful, they may act out in such a way as a protective mechanism.

In the case of dementia, delusions, and suspicious behavior are more likely to occur in the mid to later stages as the brain deteriorates. People with Alzheimer's disease show signs of suspicious behavior more often than other forms, with a reported occurrence of 30% of all cases. Nevertheless, 20% of people with all types of dementia will exude suspicious behavior at some point during the disease process.

Examples of false beliefs a person with dementia may have include "stealing," as in Martha's case, spousal infidelity, or that family members are imposters.

Ways to cope with suspicious behavior

Don't just assume that your loved one's behavior results from dementia progression. Suspicious behavior may also originate from other causes, so a healthcare provider (HCP) assessment is essential to determine why your loved one is showing signs of paranoid behavior.

Here's what you should take into consideration when trying to cope with suspicious behavior by a loved one with dementia:

Infection. If your loved one's suspicious behavior is from a treatable cause, such as a urinary tract infection (UTI) or pneumonia, prescribing antibiotics is the first step in treatment to correct delirium. Your HCP may order other lab tests and x-rays as part of the assessment.
Abnormal lab results. Depending on the abnormal lab value, your HCP will assess the results and order the best treatment plan to address the issue.
Medication reaction. With the cause being an adverse effect of a medication, your HCP will need to review the treatment plan to make any necessary adjustments. Suppose your HCP rules out a treatable cause, and the behavior is due to your loved one's declining neurocognitive status. In that case, drug-free strategies should be the first consideration in managing behavior.
Tone. Speak quietly and calmly to your loved one. Depending on your loved one's stage of dementia, you can try to explain the truth that their belief may not be accurate. Resist the urge to argue your point if they disagree.
Tension. Watch for outward expressions of anxiety. Due to a lack of insight and difficulty processing a situation, your loved one may be more adamant that you're mistaken. This conflict may cause your loved one to have increased anxiety and escalated behavior.
Redirection. In some cases, redirecting, distracting, or changing the topic may be more effective in de-escalating behavior. For example, you may introduce a new subject they find enjoyable, such as their favorite hobby or pet, or take them outside for a walk.
Validation. If your loved one shows signs of fear when expressing suspicion, it is often better to validate their feelings and not debate or argue the point. Say things such as, "That must be very upsetting to you," or "You seem afraid right now".
Environment. Be mindful of the environment, such as active or violent shows playing on the television or loud noises. An overwhelming environment can fuel suspicion and escalate the behavior.

When are medications appropriate?

Medications such as cholinesterase inhibitors or antidepressants may already be in use due to a dementia diagnosis and could offer some stabilization of behavioral symptoms. However, in cases where delusions cause severe paranoia, fear, or risk of physical harm, and drug-free strategies have been exhausted, your HCP may consider a low dose of antipsychotics for your loved one.

Additionally, antipsychotics carry health risks for older adults, such as increased incidents of falls, diabetes, and cardiac disease. Therefore, they are recommended for only short-term therapy — from 6–12 weeks to reduce complications. However, before starting treatment, a thorough medical assessment, including lab tests and ECG (electrocardiogram), by your HCP is necessary to assess the best option.

When your loved one with dementia exhibits suspicious behavior, it can be distressing for you since they may direct their suspicions to you as their primary caregiver. You first need to contact your HCP regarding any new or increased behavior for an assessment and possible treatment. Contacting your local Alzheimer's Association for support and education to help you with these and other non-pharmacological strategies to optimize health and well-being for you and your loved one.