Visual Hallucinations in the elderly
👵👴 Hallucinations in the elderly often respond best to reassurance, distraction, and supportive activities.
💊 Drug treatment is only needed if hallucinations are distressing or pose a safety risk.
🩺 Assessment
- Clinical Assessment: Detailed history & physical exam to define type, frequency, and triggers of hallucinations 🔍.
- Medical History: Explore neurological (dementia, Parkinson’s), psychiatric, and systemic illnesses 📋.
- Neuroimaging: MRI/CT to exclude structural pathology (stroke, tumour, haemorrhage) 🧠.
- Laboratory Tests: Screen for metabolic derangements, infection, thyroid dysfunction, or toxins 🧪.
- Cognitive & Psychiatric Evaluation: Assess for delirium, dementia, or psychosis 🧩.
- Medication Review: Many drugs (opioids, steroids, anticholinergics, dopaminergic therapy) may provoke hallucinations 💊⚠️.
📊 Common Causes of Visual Hallucinations in Older Adults
- 🧠 Dementia (esp. Lewy Body): Progressive cognitive decline with vivid, recurrent visual hallucinations.
👉 Managed with cholinesterase inhibitors (e.g., rivastigmine) and supportive strategies.
- 🚶 Parkinson’s Disease: Dopaminergic therapy can trigger hallucinations.
👉 Adjust medications, consider low-dose quetiapine or clozapine if necessary.
- ⚡ Delirium: Acute, fluctuating confusion due to infection, dehydration, or polypharmacy.
👉 Treat underlying cause, optimise environment, and provide supportive nursing care.
- 💊 Medication Side Effects: Opioids, steroids, benzodiazepines, and dopaminergic drugs can provoke hallucinations.
👉 Review prescription list and deprescribe if possible.
- 🌀 Psychiatric Disorders: Schizophrenia, severe depression, or mania with psychosis may present with hallucinations.
👉 Requires psychiatric input, antipsychotic therapy, and CBT.
- 🍷💉 Substance Use / Withdrawal: Alcohol withdrawal (delirium tremens), illicit drug use.
👉 Managed with detoxification, supportive therapy, and liaison psychiatry.
🛠️ Management Principles
- Treat Underlying Conditions: Correct infection, metabolic imbalance, or remove offending medications 🧾.
- Pharmacological:
- ⚠️ Low-dose antipsychotics (quetiapine, risperidone) only if hallucinations are distressing or dangerous.
- 💊 Cholinesterase inhibitors in dementia-related hallucinations.
- 🚫 Avoid typical antipsychotics (haloperidol) in Parkinson’s or Lewy Body Dementia due to severe sensitivity.
- Psychosocial:
- 🧩 Cognitive Behavioural Therapy (CBT): To manage distress.
- 🏡 Environmental Adjustments: Good lighting, clear orientation cues, calm surroundings.
- 👨👩👧 Family/Caregiver Education: Explaining benign vs. harmful hallucinations, and reducing stressors.
- Supportive Care:
- 🎶🎨 Encourage distraction and activities (music, crafts, walks).
- ⏳ Regular monitoring and follow-up to review progression and treatment effect.
💡 Clinical Pearls
- 👁️ Visual hallucinations are strongly associated with Dementia with Lewy Bodies compared to Alzheimer’s.
- 🔎 Always rule out delirium before assuming psychiatric or degenerative causes.
- 🌿 First-line = reassurance, distraction, supportive environment. Drugs only if symptoms are severe or unsafe.
