Makindo Medical Notes

👵👴 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.