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. These symptoms are known as dementia-related psychosis. They can cause fear, agitation, and frustration — for both the person with Alzheimer’s and their caregivers.

There’s no cure for Alzheimer’s disease, but some treatments can help manage symptoms. This article will cover medications, therapeutic approaches, and ongoing research. Understanding these options can help caregivers make informed choices and provide better care.

Understanding Alzheimer’s Psychosis

Symptoms of dementia-related psychosis can occur in up to 70 percent of people with Alzheimer’s disease. They most often appear in the middle to late stages of the disease, but they can happen early on, too.

Symptoms

Dementia-related psychosis symptoms include hallucinations (seeing or hearing things that aren’t real) and delusions (firmly held false beliefs). They 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. They may even lead to aggression, agitation, or withdrawal. Other symptoms might include:

• General emotional distress
• Anxiety or depression
• Sleep issues, including sleeping too much or not enough
• Physical or verbal outbursts
• Irritability
• Restlessness

People with Alzheimer’s disease psychosis may 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 is unknown, sundowning 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

Psychotic symptoms of Alzheimer’s are caused by changes in the brain. As cognitive decline worsens, the brain struggles to process information correctly. This can lead to misinterpretations of reality. Changes in brain chemicals, such as serotonin and dopamine, also play a role. Other contributing factors include:

• Stress
• Poor sleep
• Changes in the environment, such as being moved to a new residence or nursing home
• Certain genes linked to both schizophrenia and Alzheimer’s disease
• Other medical conditions, such as Parkinson’s disease or Lewy body dementia

FDA-Approved Treatment for Alzheimer’s Psychosis

In May 2023, the U.S. Food and Drug Administration (FDA) approved brexpiprazole (Rexulti) to treat agitation in people with Alzheimer’s disease. It’s the first and only medication with this specific approval.

Medications aren’t the only way to help manage psychosis in Alzheimer’s. Behavioral strategies can make a big difference in reducing troublesome symptoms, too.

Brexpiprazole works by acting on brain receptors that help control mood, thinking, and perception. By adjusting the activity of serotonin and dopamine, it may help reduce agitation, aggression, and distressing visual hallucinations or delusions. However, like most medications, it can have side effects. These may include:

• Headache
• Dizziness
• Urinary tract infection
• Sleep problems

Some people notice improvements within a few weeks, but for others, it may take up to two to three months to see the full effects. Regular checkups with a neurology (brain) specialist are important. They’ll be sure to monitor for progress and side effects.

Other Medications Used To Treat Alzheimer’s Psychosis

Even though brexpiprazole is the only FDA-approved medication for agitation in Alzheimer’s, doctors sometimes prescribe other antipsychotic drugs off-label (outside of the FDA-approved uses) to treat psychosis symptoms. These medications were originally developed to treat schizophrenia and other mental health disorders. However, some may help with psychotic symptoms in dementia.

Atypical Antipsychotics

Atypical antipsychotics (also known as second-generation antipsychotics) are sometimes used to treat psychosis in Alzheimer’s disease. These medications are FDA-approved for other psychiatric conditions, such as schizophrenia. However, doctors commonly prescribe them off-label.

Clinical trials give people with Alzheimer’s a chance to try new treatments and help advance medical science. If you’re interested in taking part, reach out to your healthcare team.

Some common atypical antipsychotics for Alzheimer’s psychosis include:

• Aripiprazole (Abilify)
• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)

While atypical antipsychotics may be helpful for some people, they come with risks. Side effects can include dizziness, increased fall risk, weight gain, and a higher risk of stroke in older adults. Because of these risks, doctors may prescribe them at low doses. Regular checkups are important to monitor for side effects, too.

Typical Antipsychotics

Older drugs like haloperidol (Haldol) are sometimes used in emergencies. Or, they may be chosen when someone becomes extremely agitated or aggressive. However, these drugs — also known as typical antipsychotics — have a higher risk of side effects. These can include:

• Muscle stiffness
• Tardive dyskinesia (muscle tremors)
• Extreme drowsiness
• Dry mouth
• Constipation
• Heart problems

Because of the increased risk of side effects, they’re usually not the first choice for long-term treatment. If they are used, close monitoring is essential.

Therapeutic Interventions

Medications aren’t the only way to help manage psychosis in Alzheimer’s. Behavioral strategies can make a big difference in reducing troublesome symptoms, too. Since every person with Alzheimer’s is different, it may take time to figure out what works best.

For some people, creating a calm and predictable environment can help. People with Alzheimer’s disease often feel disoriented. So, keeping their routine as consistent as possible can help prevent confusion and anxiety. Avoiding loud noises, bright lights, or sudden changes can also help keep them calm.

If a loved one becomes agitated or upset, responding with patience and reassurance is best. Trying to reason with them or convince them their delusions aren’t real may only make matters worse. Instead, validate their feelings and gently redirect their attention to another activity. For example, if they’re worried about a missing item, offer to help them look for it or distract them with something they enjoy.

Simple, comforting activities can also help reduce agitation. Soft music, favorite TV shows, looking through old photos, or going for a short walk can provide emotional comfort and relaxation. Some people find that physical touch, such as holding hands or hugging, can be soothing and comforting.

Emerging Treatments and Clinical Trials

Scientists are working to find safer and more effective treatments for psychosis in Alzheimer’s disease. Some clinical trials are testing new drugs, including pimavanserin (Nuplazid). This drug is approved for Parkinson’s psychosis. It is also being studied for use in dementia-related psychosis, Parkinson’s disease dementia, and Lewy body dementia.

Other drugs are currently in clinical trials for Alzheimer’s disease and other types of dementia-related psychosis.

Researchers are also looking at alternative treatments, such as brain stimulation therapies and new drug combinations. These may help improve symptoms while reducing side effects.

Clinical trials give people with Alzheimer’s a chance to try new treatments and help advance medical science. If you’re interested in taking part, reach out to your healthcare team to find out if you might be a fit for any trials.

Talk With Others Who Understand

On myALZteam — the social network for people with Alzheimer’s disease and dementia caregivers — more than 86,000 members come together to ask questions, give advice, and share stories.

Is your loved one experiencing symptoms of psychosis? How have you managed these behaviors? Post your thoughts in the comments below, or start a conversation on your Activities feed.