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

Management and Treatment Approaches

Current guidelines and treatment recommendations are largely based on expert consensus. The focus is typically on the overall management of a specific clinical condition, with hallucinations one of the symptoms covered, eg, NICE Guidelines for Parkinson's disease.[78] To date, few guidelines have focused on hallucinations specifically (eg,[79]) and the forthcoming SHAPED (Study of Hallucinations in Parkinson's disease, Eye disease, and Dementia) consensus guidelines will be the first to focus on visual hallucinations in older adults.

All guidelines for hallucinations take the view that different treatments for hallucinations are required at different disease or hallucination stages and that experiencing hallucinations may not, in itself, require a specific treatment beyond general measures (eg, education, reassurance, physical, and medication review). For example, the SHAPED guidelines suggest including a review of cognitive and ophthalmological health, given that these may be masked by other conditions: ie, cognitive impairment may be missed in a patient with eye disease with their decline in functional ability attributed to visual loss. Early provision of information about the risk of hallucinations is emphasized as a way of reducing stigma and for healthcare professionals to routinely ask about hallucinations—to shift the onus of reporting hallucinations away from the patient. The point at which specific pharmacological or non-pharmacological interventions for hallucinations are required is not clearly defined in guidelines but based on clinical judgment.

Differential Diagnosis

Before commencing treatment, it must be clear that hallucinations are causing distress, ie, that there is a need for treatment. If this is the case, the second point of attention is whether it is indeed hallucinations. Especially in older adults with cognitive dysfunction, it can be difficult to disentangle hallucinations from obsessions, misperceptions/misunderstandings (ie, illusions), or involuntary mental imagery, such as the so-called "earworms" (ie, songs in the mind that continually repeat).[80]

Purpose of Treatment

For some disorders, such as intoxication, psychotic depression, and schizophrenia, hallucinations may respond well to treatment of the underlying disorder. However, in other disorders, such as dementia, vision or hearing loss, or Parkinson's disease, this is not the case. In such instances, additional treatment aimed specifically at hallucinations may be indicated. For the treatment of hallucinations, the most important question is what the aim of treatment should be. There are a number of answers frequently given to this question:

  1. I want to understand why I experience these hallucinations.

  2. I want to be competent to handle these hallucinations.

  3. I want to get rid of these hallucinations.

For Purpose 1: Psychoeducation. If the response to this question is in line with answer 1, then psychoeducation is the treatment of choice. In one or more sessions, the patient and his/her loved one can be provided with information about how perception is accomplished in the brain, how this process can go awry, and which factors can precipitate hallucinations. A good start for psychoeducation is to ask the patient what he/she already knows and which explanation he/she currently uses for this experience. From there, unhelpful explanations can be corrected and new knowledge can be added to improve disease insight.

For Purpose 2: Psychological Therapy. If the answer is close to the description under point 2, then psychological therapy that helps the person to develop effective (and avoid ineffective) strategies and skills for coping with hallucinations, and any distress associated with these experiences, is recommended. Cognitive behavioral therapies help clients think and feel differently about hallucinations. Improving coping skills can also help to reduce distress, which may contribute to the onset or maintenance of hallucinations.[81] In the case of bereavement hallucinations, it is important to take a relational psychotherapeutic perspective on the experience, as the distress may signify relationship difficulties with the deceased, eg unfinished business and intrusive presence.[82,83] Several psychotherapies initially developed for treating people with a primary psychotic disorder and auditory hallucinations (cognitive behavioral therapy, COMET, acceptance, and commitment) are also applied to older persons,[84,85] though less is known about the application of cognitive behavioral therapy for distressing visual hallucinations.[86] In some cases, adjustments need to be made when the cognitive resources of patients are limited. The essence of such therapies is that the patient learns that hallucinations are not a real-life threat, may have personal significance or meaning, or can safely be ignored. If (auditory) hallucinations have neutral content, then psychotherapy developed for tinnitus may be a better fit, as it focuses on the reduction of worry, and shifting attention away from the unwanted perceptions.[87]

For Purpose 3: The Following Steps can be Used. Step 1: Check Medication: Checking medication records is important since several types of medication can induce hallucinations, especially those with anticholinergic activity and those that increase monoaminergic function. People with cognitive dysfunction are at particular risk for such side effects. The most commonly used hallucination-triggering medication are corticosteroids, levetiracetam (an anti-epileptic drug), anti-malaria medication, dopaminergic agonists (pramipexole, rotigotine, ropinirole, etc.), losartan (an antihypertensive drug), and opioids such as tramadol. If there is a correlation in time between the onset of hallucinations and start of medication use, it may be worthwhile to taper off that medicine or replace it by another one and reevaluate hallucination severity.

Step 2: Risk Factor Management: Risk factors for hallucinations include physical health, environmental, psychological, and social factors. Any obvious triggers to the hallucinations should be identified. Comorbid physical health factors increase the risk of hallucinations, including visual and hearing impairment and physical illnesses (eg, some metabolic and endocrine disorders, and psychiatric disorders such as depression and psychotic disorders). Optimize sensory modes by using glasses, perhaps cataract operation is an option, use hearing aids. Good sleep hygiene is key, with darkness in nighttime and bright lights (preferably sunlight) at day. In terms of environment, it is key to provide well-lit rooms, without dark corners. Reduce background noise as much as possible, especially during conversations. At the social level, good company is an excellent prevention for hallucinations and may reduce their frequency and intensity.

Step 3: Pharmacotherapy: If the patient wants to reduce hallucinations and previous strategies were not successful, pharmacotherapy can be an effective means to do so, although side effects may be severe, especially in older people. It is important to discuss the unstable course of hallucinations and the possibility that they will disappear spontaneously. Considering that hallucinations can arise from aberrations in many neurotransmitters systems, including the dopaminergic, serotonergic, glutamatergic, and cholinergic system, then specific medication may be effective only in specific subtypes. The phenomenology of the hallucinations may provide some clues to the direction of which receptor system may be involved.[88] For example, dopamine couples salience to experiences and increased dopamine production can lead to highly salient, often frightening hallucinations, as seen in people with psychotic depression, schizophrenia, delirium, and post-traumatic stress disorder. Antipsychotic medication can be effective for this specific type of hallucinations.[89–91] As dopamine receptors decrease with age, much lower dosages are used for older adults; hence, the adage "start low, go slow" to titrate until the lowest effective dose is achieved. Sedative antipsychotics need to be given at nightime to reduce the risk of falls. Electrocardiogram for potential QT elongation should be performed before and after the start of risperidone, aripiprazole, and typical antipsychotics.[92] As antipsychotic use has been associated with significant mortality and morbidity risks for older patients, especially those with dementia, such medication should be avoided if possible and tapered off if not effective or when hallucinations have been in stable remission when it is used.[91,93]

Hallucinations, especially in the visual domain, in older adults can also arise from the loss of cholinergic innervation, especially in people with neurodegenerative disorders, such as Alzheimer's, Huntington's, or Parkinson's disease. As acetylcholine is an important neurotransmitter in sustained attention, patients with loss of cholinergic innervation often show drowsiness, inattention, and forgetfulness ("what was the reason I went to the kitchen?"). Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine can be effective in treating this type of hallucination.[94,95] If using rivastigmine, patches may be better tolerated than pills as they provide fewer gastrointestinal side effects.[96,97] Starting dose is usually 4.6 mg/24 hours, which is increased to 9 mg/24 hours after 3–5 weeks if generally tolerated, although side effects are also common.[98]

Step 4: Physical Therapy: In older individuals, pharmacotherapy often induces side effects. Further, antipsychotic medication use in the elderly has been associated with increased mortality.[91,93] Hence, an alternative treatment may be to use electrical or magnetic therapies. Electroconvulsive therapy (ECT) is not only the best-known option but also the most intensive one. ECT may be an excellent option for older adults with psychotic depression as it is rapid and highly effective for both the depressive and the psychotic symptoms. Cognitive side effects can occur but are generally not lasting and may be ameliorated by the use of cholinesterase inhibitors during the ECT course.[99] For other types of hallucinations in older adults, ECT is seldom used. Transcranial magnetic stimulation and transcranial direct (or alternating) current stimulation have been mostly applied for auditory verbal hallucinations,[100,101] but could also be an option for tactile hallucinations.[102,103]