“It’s Just Bad Behavior.” — The Hidden Reality Behind Delusions and Hallucinations in Dementia
Every week I sit with families who are exhausted and say the same thing: “Dr. Erik, how do I handle these behavioral issues? She accuses me of stealing her things, or she’s talking to people who aren’t even there.”
It can feel personal. It can feel impossible. But these are not “bad behaviors.” They are the natural reaction to a frightening, altered reality caused by dementia — and once you understand what’s really happening, you can respond in a way that actually helps.
My name is Dr. Erik Ilyayev. I’m a dementia care physician, a board member of the South Florida Alzheimer’s Association, and the CEO of MedBetter Health — one of the organizations selected by Medicare to participate in a groundbreaking new program designed to change how America cares for people living with dementia.
In this issue, I explain the real difference between delusions and hallucinations, why they happen, and the simple strategies that can calm the storm.
DELUSIONS vs HALLUCINATIONS — What’s Really Going On
Delusions are false beliefs the person holds as absolute truth.
Common ones include:
• “You stole my earrings / money / clothes”
• “My spouse is having an affair”
• “You’re trying to hurt me or kill me”
Hallucinations are false sensory experiences — seeing, hearing, or feeling things that aren’t there.
Examples: seeing a deceased parent standing in the room or hearing children playing when the house is quiet.
Here’s the important part most families miss:
The person’s brain has created an altered reality. That altered reality triggers fear, confusion, or anxiety — which then explodes into the behavior we see (agitation, anger, accusations, or withdrawal). In their world, these experiences are completely real.
WHAT YOU CAN DO TODAY
Step 1 – Rule out medical causes first
If the delusions or hallucinations are new or suddenly worse, never assume “it’s just the dementia.” Check for reversible triggers like:
• Urinary tract infections (very common)
• Dehydration or low sodium (especially if on diuretics)
• New medications, pain, low oxygen, or poor vision/hearing
Step 2 – Respond with validation and redirection
- Acknowledge their feelings without arguing: “I see you’re upset. I’m right here.”
- Never argue with their reality — it only increases fear.
- Validate, then gently redirect. Example: “Mom, let me check for that ghost… okay, all gone. Why don’t we sit together and look at your favorite photo album?”
Remember: Don’t take the accusations personally. Their brain is changing — their love for you hasn’t.
Common questions
Quick answers from this issue
Delusions and Hallucinations
“It’s Just Bad Behavior.” — The Hidden Reality Behind Delusions and Hallucinations in Dementia Every week I sit with families who are exhausted and say the same thing: “Dr. Erik, how do I handle these behavioral issues? She accuses me of stealing her things, or she’s talking to people who aren’t even there.” It can feel personal. It can feel impossible. But these are not “bad behaviors.
What should caregivers try first?
Write down what changed, when it started, and what was happening right before it. Reduce noise, slow the conversation down, and use one simple step at a time. Share the pattern with the family, care team, or clinician so everyone responds consistently.
When should families call a clinician?
Call a clinician promptly if the change is sudden, severe, unsafe, tied to a fall, fever, pain, dehydration, medication change, hallucinations, paranoia, or new confusion. Call emergency services for immediate danger.