When the Mind Plays Tricks: Understanding Psychosis, Dementia, and Alzheimer’s in the Elderly

We expect the body to slow down as we age. We expect wrinkles, stiff knees, and even some forgetfulness. What we rarely expect — or talk about — is when the mind begins to play tricks on itself.

An older loved one starts seeing people who aren’t there, or accuses the neighbors of spying. Someone you care for becomes suspicious, confused, or hears voices whispering when no one else can hear them.

Is this psychosis?
Is it dementia?
Is it Alzheimer’s?

And most importantly: what can you do about it?

Let’s untangle this knot together.

What is Psychosis?

Psychosis is a mental condition where a person loses touch — partly or fully — with reality. This isn’t simply eccentric behavior or stubbornness. Psychosis is marked by symptoms like:

• Delusions — strong, false beliefs (e.g., “You’re poisoning my food,” when you are not.)

• Hallucinations — seeing, hearing, or feeling things that others do not.

• Disorganized thinking and speech — sentences that don’t make sense or thoughts that jump wildly.

Psychotic disorders, like schizophrenia, usually begin in young adulthood. It’s rare, but not impossible, for them to first appear after age 60 — something called late-onset schizophrenia.

In the elderly, however, psychosis is more often a symptom of something else — such as dementia, Alzheimer’s, medication side effects, or a sudden medical illness.

How Common is Psychosis in the Elderly?

Here’s the honest truth: primary psychotic disorders in the elderly are rare. About 0.2–4% of people over 65 have schizophrenia or a similar condition.

What’s much more common is what doctors call “secondary psychosis” — when hallucinations or delusions happen because of another condition, such as:

• Dementia

• Delirium (acute confusion from infection, dehydration, or medication)

• Severe depression with psychotic features

• Medication side effects

So if an elderly loved one begins to see things, hear voices, or believe strange things, it doesn’t automatically mean they’ve “gone crazy.” It does mean it’s time for a professional evaluation.

Dementia & Alzheimer’s: How Are They Different?

Dementia is a gradual decline in memory, thinking, and functioning that interferes with daily life.
Alzheimer’s is the most common type of dementia, with specific brain changes (like amyloid plaques) behind it.

In dementia and Alzheimer’s, you often see:

• Memory loss

• Poor judgment

• Getting lost or confused about time

• Difficulty speaking or following a conversation

And yes — around 30–50% of people with dementia will also experience hallucinations or delusions at some point.
That’s why it can look like psychosis, even though the root cause is different.

A Simple Way to Understand the Difference

Think of the mind as a house:

• Psychosis is a cracked mirror. The house is still standing, but the reflection of reality is warped.

• Dementia is the foundation crumbling slowly. The house itself becomes less stable, and rooms “disappear.”

• Alzheimer’s is one specific kind of foundation damage — the most common kind.

And then there’s delirium — a sudden storm that blows through and scrambles everything temporarily, but can often be treated and reversed.

Why This Matters

Knowing the difference is crucial because the treatments are very different:

• Psychosis: Antipsychotic medications, therapy, and support.

• Dementia & Alzheimer’s: Memory-enhancing medications, routines, and caregiver support.

• Delirium: Identifying and treating the underlying medical cause quickly.

If your loved one shows signs of confusion, hallucinations, or delusions:
✅ Take note of when the symptoms began — sudden or gradual?
✅ Observe whether memory loss or confusion came before or after hallucinations.
✅ Get a medical evaluation — preferably from a geriatric psychiatrist or neurologist.
✅ Don’t argue with delusions — stay calm, kind, and supportive.
✅ Rule out infections, medication side effects, and other reversible causes first.

Final Thoughts

Even the oldest tree can sprout a strange new branch — but it’s important to know whether it’s a healthy shoot or a sign of rot beneath the bark.

Aging minds deserve just as much care and attention as aging bodies. When an elder begins to act strangely, it’s not a time for shame, but a time for clarity, compassion, and professional help.

Sometimes it’s a cracked mirror; sometimes it’s a crumbling foundation. Either way — with vigilance and care, you can keep the house standing, and even let some light back in through the windows.

If you or someone you love is showing signs of psychosis, dementia, or Alzheimer’s:

📞 Call your doctor.
📝 Write down what you see.
👣 Take one step at a time — and don’t walk the path alone.

If you’d like, I can also share a printable checklist of what to watch for and what to ask your doctor — just ask in the comments or send me a message.

“When the mind wanders into shadow, be the steady hand on the lantern.”