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


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

In This Article

Assessment Tools

For the purposes of this review, clinicians and researchers with particular expertise in hallucinations in older populations were asked to provide a list of key elements that underpin high-quality assessment tools as well as features specifically relevant to tools for assessing hallucinations in older adults (step 1). Thereafter, these same experts were asked to provide a list of existing assessment tools for hallucinations that may be used with older adults and describe their strengths and limitations (step 2). Finally, these assessment tools were summarized and compared with the elements from step 1.

Criteria for Assessment Tools

A list of the key elements that underpin high-quality assessment tools is presented in Table 3[45,46] whereby general issues are presented first, followed by psychometric, structural, and practical issues that are specific to the assessment of hallucinations and to the context of assessing older adults in particular.

Summary of Existing Assessment Tools for Hallucinations

Table 4 presents a selection of commonly used assessment tools for hallucinations, along with a brief summary of their psychometric properties, and their strengths and limitations. Of note, the majority of these measures were not developed specifically for older adults—so that their design was not necessarily based on the needs of older adults or any specific characteristics of hallucinations in older age groups.

In Table 4, it can be seen that, compared with self-report measures, there are relatively few clinician-administered tools regularly used with older adults. One of these (Assessment of Phantosmia) is for a very specific type of hallucination (ie, only for olfactory hallucinations), although it has been used in older populations[67] (cf.[68]). Another tool, the Auditory Hallucinations Rating Scale[62,63] is quite brief and assesses just auditory hallucinations, but is not widely used (for transcranial magnetic stimulation studies only). The North East Visual Hallucinations Inventory[64–66] has good psychometric properties and was developed with older populations in mind but assesses only visual hallucinations. The final two interview tools—the Psychotic Symptom Rating Scales (PSYRATS)[60] and the Questionnaire for Psychotic Experiences (QPE)[69]—are quite similar, in that both are detailed in the number of dimensions they assess, although the QPE offers a more complete assessment of hallucinations modalities and delusions, whereas the PSYRATS assesses delusions but only auditory hallucinations.[61] Important to note is that the PSYRATS was developed for the assessment of patients with psychotic disorder, so it is arguably less suitable for older clinical groups where, eg, visual (and other) hallucinations dominate. However, the PSYRATS does show sensitivity to change and is, therefore, widely used in evaluating the treatment of hallucinations (cf.[70–73]). Although the PSYRATS has been in use for two decades, to the best of our knowledge, it has not been systematically investigated in older populations. Finally, it is still unknown if hallucination measures are invariant across samples, making comparisons of scores between different samples (eg, older adults and people with psychosis) invalid.

In terms of self-report measures, many of these assess hallucinations in a number of different modalities (eg, Cardiff Anomalous Perceptions Scale, CAPS;[53–55] Multi-Modality Unusual Sensory Experiences Questionnaire, MUSEQ;[59] Launay-Slade Hallucinations Scale, LSHS;[47] Extended LSHS[48–50]), and others are less comprehensive (eg, Community Assessment of Psychic Experiences, CAPE,[51,52] and Current CAPE-15).[58] Some measures were designed to assess hallucinatory experiences in older populations with a particular disorder—such as Parkinson's disease, eg, Psychosis and Hallucination Questionnaire[56,57]—whilst others were not specifically created for assessing hallucinations in a particular disorder (CAPS and E-LSHS) but have recently been used in the clinical studies of older populations, eg, the E-LSHS has been used in people with Alzheimer's and older nonclinical populations.[74–76] However, as with clinician-administered tools, very little research has directly compared the use of these self-report measures across age groups, ie, younger vs older adults (but see[8,77]) and/or diagnostic groups (ie, clinical vs nonclinical), and it, therefore, remains largely unknown whether these tools are sample invariant. This is important to consider, because if older adults are shown to be using existing tools differently to younger adults, then changes may need to be made to these tools to accommodate for this; in turn, this will help to ensure that these experiences can be assessed, and validly compared, across different groups.

Overall, clinician-administered interviews are often already in a suitable and convenient format for older adults—difficulty reading due to visual loss/impairment, items can be repeated for those with hearing loss—though clinicians sometimes lack confidence in talking about hallucinations, so formal training is required to learn how to approach this topic and to administer items in a standardized way. For example, the QPE,[69] which was developed with input from patient associations in several countries, provides 50 fully structured questions about hallucinations and is scripted to be low in stigma. However, interviews can be time-consuming, which may be a problem for adults with cognitive or motivational difficulties. To conclude, there is a clear need for an increased interest in hallucinations in older adults, both in terms of research in general and in terms of clinical practice (eg, the development and validation of optimal hallucination assessment tools for older adults and the existence of formal clinical training related to hallucinations in older adults). We encourage those working in a clinical setting to use the information presented here to choose the optimal hallucination assessment tools for their working context. These assessment issues are as important in a clinical setting as they are in research. Also, we recommend that clinicians strive to further adapt, refine, and validate these tools to reduce the gap in evidence-based assessment tools available for older adults.