The Geriatrics For Caregivers Blog

Q: My mother is 80.  She is very active (despite breaking her hip 2 years ago), she still attends water therapy 3 times a week at the YMCA, she drives to the base (which is 20 miles away) and pays her bills on time.  She is a retired Psych nurse and has shown signs in the past of paranoia. 

Lately, she has “heard” voices of her grandchildren in her home and called my sister. She also has difficulty with getting the right words to say out and has her sleep pattern out of whack and will call people at odd times of the night.  With her independence comes the fact she won’t share any medical information because she thinks we are out to get her committed.  

How can I test her/question her to find out the level of decline she may be in to make sure she is safe? — K

A: Great question. As you may know, it’s fairly common for aging parents to develop problems like the ones you are describing. Understandably, these problems are frustrating and worrying for adult children.

You are absolutely right to be concerned about your mom’s safety. I do have some ideas for how you can get started assessing her, which I share below.

But first I want to explain the most common causes of this type of behavior in older adults. That’s because one of the things you must do is help your mother and the doctors figure out why she’s developed these behavior changes and other symptoms.

A fair number of people don’t get around to the medical evaluation because they assume that these crazy behaviors are either normal aging (definitely false) or dementia such as Alzheimer’s (true about 40% of the time).

Furthermore, it’s often hard to get a resistant older parent medically evaluated.

Still, it’s worth persisting in this, because many causes of paranoia or other odd behavior in older people can be treated.

Paranoid symptoms (e.g. believing that someone is out to get you, or is taking your stuff, or is in the house at night) falls into a category of mental symptoms that is technically called “psychosis.”

Symptoms of psychosis can include:

• Delusions, which means believing things that aren’t true or real.
• Hallucinations, which means seeing or hearing things that aren’t there.
• Disorganized thoughts or speech, meaning saying or thinking things that seem illogical or bizarre to others.

Psychosis is uncommon in younger people but becomes much more common as people get older. That’s because any of these symptoms can emerge when people’s brains aren’t working properly for some reason.

A 2015 review article on “late-life psychosis” estimates that 23% of people will develop symptoms of psychosis in late life.

I like this review article because the authors organize the causes of late-life psychosis into six “Ds”:

• Delirium (10 %).
  • This is a very common condition of “worse-than-usual” mental function, often brought on by the stress of severe illness, surgery, or hospitalization. See 10 Things to Know About Delirium for more.

• Drugs, alcohol, and other toxins (11%)
  • Medication side-effects can cause delusions, hallucinations, or other forms of psychosis. Pay special attention to medications known to affect memory and thinking. Abuse of — or withdrawal from — alcohol or other substances can also cause psychosis symptoms.

• Disease (10%)
  • Many physical health problems can interfere with brain function. These include electrolyte problems such as abnormal levels of sodium, potassium, calcium, or magnesium in the blood, low levels of vitamin B12 or folate, thyroid problems, severe liver or kidney dysfunction, infections, and neurological diseases. Brain damage from minor strokes can also cause psychosis symptoms.
  • Urinary tract infections can cause psychosis, but in my experience, they are almost never the cause of paranoia or other symptoms that have been going on for weeks, months, or longer. (A positive urine culture in an older person who has been having psychosis symptoms for a while probably reflects a colonized bladder.)

• Depression (33%) and other “mood disorders,” including bipolar disease (5%)
  • About 15% of people with major depression may experience psychotic symptoms. Delusions of guilt or deserved punishment are especially common.

• Dementia (40%), including Alzheimer’s disease, Lewy-Body dementia, and others
  • Delusions are extremely common in dementia, especially delusions of theft, spousal infidelity, abandonment, and persecution. Hallucinations (especially visual hallucinations) are also common, especially in Lewy-Body dementia. For more on how dementia is diagnosed, see How We Diagnose Dementia: The Practical Basics to Know.

• Delusional disorder (2%) and schizophrenia-spectrum disorders (1%)
  • These two conditions have many symptoms that overlap with those of dementia, delirium, or other conditions affecting thinking. Doctors must exclude these more common conditions before diagnosing a person with schizophrenia or delusional disorder. Schizophrenia affects an estimated 0.1-0.5% of people over age 65. Many were diagnosed earlier in life but some people can develop the condition later in life. Delusional disorder affects an estimated 0.03% of older adults.

The authors of this review article also note that it’s common for older adults to have vision and hearing problems, both of which can trigger or worsen delusions and hallucinations.

So as you can see, when older adults experience delusions, hallucinations, and paranoid thoughts, there is almost always something more going on with their health. Figuring out what is beneath the “crazy” or “irrational” or “paranoid” behavior is key.

Hence I recommend you keep these six causes of paranoid symptoms in mind, as you try to find out more about how your mom has been doing.

How to check on “levels of decline” and safety

It’s great for you to be proactive and want to help check on your mother safety and situation. Ultimately you’ll need to work with professionals, but you can speed the process along by checking for common red flags, and bringing them to the attention of your mother’s doctor.

As a geriatrician, I generally try to assess an older person in the following five domains:

• Ability to manage key life tasks
  • These include the ability to manage Activities of Daily Living (key tasks we usually learn as young children, such as walking, dressing, feeding ourselves, and toileting) and also Instrumental Activities of Daily Living (key tasks we learn as teenagers, such as managing finances, transportation, meal preparation, home maintenance, etc).
• Safety red flags
  • This includes signs of financial vulnerability or exploitation, risky driving, leaving the stove on, wandering, or signs of elder abuse.
• Physical health red flags
  • These include weight loss, declines in strength or physical abilities, falls, frequent ER visits, and complaints of pain.
• Mood and brain health red flags
  • These include common signs of depression (especially sadness and/or loss of interest in activities), signs of loneliness or isolation, new or excessive worrying, as well as other signs of memory and thinking problems
• Medication management red flags
  • These include signs of difficulty taking prescriptions as directed, checking on possible medication side-effects, and identifying medications that are on the Beer’s list of medications that older people should avoid or use with caution.

Because concerned family members often ask me about checking on an older parent, I created a guide with five checklists based on the five sections above.

You can print the guide and use the checklists to spot these red flags that often represent serious safety or health problems.

Now, no guide is going to enable you to diagnose your parent. And no guide can guarantee that you’ve identified and addresses the most important safety issues. You’ll need to work in person with professionals to do that.

But by being methodical in observing your mom and in documenting your observations, you will make it much easier for professionals to figure out why your mother has developed these behaviors you are concerned about.

Also, by identifying specific red flags or problem areas, you’ll be better equipped to work with your mom and other family members on addressing safety concerns. That’s because it’s much more effective to focus on issues that are specific and concrete (“I noticed that you seem to be having trouble with your grocery shopping”), rather than simply telling an aging parent that you are worried about their safety.

Tips on following up on safety issues and memory problems

Once you’ve identified safety issues and signs of underlying health problems, you’ll want to follow up. You’ll need health professionals to help evaluate and manage any underlying health problems, and you may find you need help from other types of experts as well.

If your older parent is paranoid and resisting your involvement, this often becomes a stuck spot for families.

How to get unstuck depends on the situation. Here are some ideas that often help:

• Relay your concerns to your parent’s doctor. The doctor needs to know about the symptoms and problems. The doctor may also be able to persuade your older parent to accept some help, or even the presence of another family member during medical visits.
  • Patient privacy laws (e.g. HIPAA) do not prevent families from providing information to a person’s doctor over that person’s objections.
  • The doctor will probably not disclose health information to you but may do so under certain circumstances. That’s because when a patient is “incapacitated”, doctors are allowed to disclose relevant health information to family members, if they feel it’s in the best interest of the patient. For more on when health providers may disclose information to family members, see 10 Things to Know About HIPAA & Access to a Relative’s Health Information.
  • If you send your concerns in writing, they will probably be scanned into the medical record.
  • Also ask if any social work services are available through your parent’s health provider.

• Contact organizations that support older adults and families, for assistance and for referrals. Some good ones to try include:
  • Your local Area Agency on Aging; find it using the locator here.
  • Family Caregiver Alliance. The navigator showing state-by-state services is especially nice.
  • Local non-profits serving seniors and families. Try using Google to find these.

• Get help from a geriatric care manager (now known as aging life care professionals) or other “senior problems” expert. This usually requires paying out-of-pocket, but can enable more hands-on assistance than is usually available through social workers and non-profits.
  • The ideal person will be good at difficult conversations with older adults, will be able to help you communicate with doctors if necessary, and will know what local resources are available to address any safety or living issues you detect.

• Get advice from other adult children who have faced similar situations. You can find caregiving forums and message boards online, where people share ideas on getting through these challenges.
  • There’s an active forum of people caring for older relatives at AgingCare.com.  You can find a lot of ideas and support there. However, most such forums have minimal moderation from professionals, so you should double-check on any medical, legal, or financial advice you get.
  • Daughterhood.org is a website and community for people helping older parents. Look to see if they have a local “Circle” near you.

• Consider contacting Adult Protective Services if you think this might qualify as self-neglect. Self-neglect means an older person is living in a way that puts his or her health, safety, or well-being at risk. It’s not uncommon for older adults with memory or thinking problems to self-neglect.
  • This is considered a form of elder abuse and can be reported to Adult Protective Services (APS).
  • For a good overview of self-neglect and how APS can get involved, see here.
  • In most states, health providers and certain other professionals are “mandated reporters” for elder abuse and self-neglect, which means they are supposed to report any such suspected cases to APS.

When it comes to contacting the doctor and hiring an expert to help, it’s best if you can get your mom’s agreement before proceeding. (Or at least, not have her explicitly forbid you from doing these things). Here are some tips to help with your conversations:

• Use “I” statements as much as possible. “I’ve noticed you’ve been calling people during the night. I’ve noticed you sometimes have difficulty with your words. I’m concerned and I’ve heard it’s important to have such symptoms evaluated by a doctor, because they can be due to treatable medical problems.”

• Frame any suggestions you make as a way to help your mother achieve her goals. For most older adults, these include living at home for as long as possible, maintaining good brain function and physical function, and otherwise remaining as independent as possible.

• Avoid relying on logic. Logic never works well when it comes to emotionally-charged subjects. And it especially doesn’t work if people are experiencing any difficulties with memory or thinking. So don’t expect your mom to be logical and don’t rely on logical arguments to convince her.

For more on approaching a parent who is resistant to help, I explain how to do this in my free online training for families:

Now, if you find it causes your mother intense anxiety or agitation to discuss your concerns and your suggestions for helping her, it may be reasonable to just proceed. After all, you do have reasons to believe that some kind of health issue is affecting her thinking.

So especially if you’ve identified any safety problems, it’s reasonable to move ahead despite her preference that you not intervene.

In closing, I’ll reiterate that this is a very tough situation to navigate, and it usually takes time and persistence for families to make headway. Do try to take care of yourself as you work through this. Connecting with others facing similar challenges is a great way to get support and practical ideas on what to do next.

Good luck!

This article was first published in 2016; it was reviewed & minor updates were made in August 2022.