Hallucinations in Older Adults: A Practical Review

Johanna C. Badcock; Frank Larøi; Karina Kamp; India Kelsall-Foreman; Romola S. Bucks; Michael Weinborn; Marieke Begemann; John-Paul Taylor; Daniel Collerton; John T. O'Brien; Mohamad El Haj; Dominic ffytch; Iris E Sommer

Disclosures

Schizophr Bull. 2020;46(6):1382-1395. 

In This Article

Abstract and Introduction

Abstract

Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.

Introduction

General Introduction

By 2050, it is estimated that 16% of people will be aged above 65 years, compared with 9% in 2019.[1] Population aging is driving increased attention to the physical and mental health needs of older adults. Here, our focus is on hallucinations—given the wide range of health and aged-care service providers who encounter people with these experiences in their workplace. Hallucinations can be defined as "a perception-like experience with the clarity and impact of a true perception but without the external stimulation of the relevant sensory organ"[2] (cf.[3–5]), though this belies the difficulty in discerning the boundaries between normal and abnormal perception.[6] Hallucinations need to be distinguished from illusions, which are perceptual experiences in which an external stimulus is misperceived or misinterpreted.[2] In practice, hallucinations vary in content (eg, perception of people, animals, or objects), character (eg, frequency, emotional valence, location), duration (from seconds to chronically present), complexity (eg, perception of simple stimuli vs organized scenes or objects), and quality (eg, perceived reality, intrusiveness) and occur in all sensory modalities. The terms used to refer to hallucinations are equally diverse (see Table 1).

Hallucinations occur in people with sensory, neurological, medical, neurodegenerative, and psychological disorders[7] as well as in those with no mental disorder at all.[8–10] In healthy (nonclinical) samples, hallucination prevalence (across modalities) is lower in older than younger adults.[8,9] In contrast, hallucinations are common in many clinical disorders associated with older age, with specific prevalence rates varying by condition, stage of illness, and symptom type. For example, visual hallucinations are common in dementia, Parkinson's disease, and in eye or visual pathway disease,[11] while auditory hallucinations are prevalent with hearing loss.[12] Similarly, multimodal visual, tactile, and auditory hallucinations tend to be more prominent in late- (between 40 and 60 years age) or very-late onset (60+ years) compared with early-onset schizophrenia.[13] Across conditions, both similarities and differences have been reported,[14,15] suggesting that the same assessments and treatments may not be appropriate for all presentations of hallucinations in older adults, which may be linked to the diversity of risk factors involved.[16–19]

Whilst our understanding, assessment, and treatment of hallucinations in older adults have improved in the last decade, greater priority needs to be given to communicating these advances to clinicians so that clinical care can be grounded in the best available evidence. The International Consortium of Hallucinations Research Working Group on Hallucinations in Older Adults was set up to respond to this challenge. Accordingly, the purpose of this review is to highlight the key issues for the workforce caring for older adults with hallucinations; critically review current assessment tools, management guidelines, and treatment approaches for this population; and offer recommendations and resources to support best practice.

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