Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management.

Iracema Leroi, Dominic Ffytche, Rimona Sharon Weil, Prabitha Urwyler, Alan Thomas, Peter Swann, Gregor Russell, Rebecca Pinto, Marco Onofrj, Kirsty Olsen, Claire O'Callaghan, Chaitali Naik, Michel Michaelides, Ian McKeith, John O'Brien, Vanessa Lawrence, Kate Harris, Andrea Gibbons, Paul Francis, Rob Dudley, Sonali Dave, Daniel Collerton, Alistair Burns, Clare Bradley, Roger A Barker, Clive Ballard, John Paul Taylor

Journal: Journal of neurology, neurosurgery, and psychiatry 2020;91(5):512-519

PMID: 32213570

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Abstract

Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson's disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson's disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.

Address: Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK [email protected].; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.; University of Exeter Medical School, Medical School Building, St Luke's Campus, Exeter, UK.; Department of Clinical Neurosciences, WT-MRC Cambridge Stem Cell Institute, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK.; Health Psychology Research Ltd, Egham, Surrey, UK.; Health Psychology Research Unit, Royal Holloway University of London, Egham, Surrey, UK.; Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom.; Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK.; Gateshead Early Intervention in Psychosis Service, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, Gateshead, UK.; Global Brain Health Institute, Department of Psychiatry, School of Medicine, Trinity College Dublin, Dublin, Ireland.; Moorfields Eye Hospital NHS Foundation Trust, London, UK.; Institute of Ophthalmology, University College London, London, UK.; Brain and Mind Centre and Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.; Clinical Neurologica, Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, Università G.D'Annunzio, Chieti-Pescara, Italy.; Bradford District Care NHS Foundation Trust, Lynfield Mount Hospital, Bradford, UK.; Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK.; Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland.; University Neurorehabilitation Unit, Department of Neurology, University Hospital Inselspital, Bern, Switzerland.; Dementia Research Centre, University College London, London, UK.

DOI: 10.1136/jnnp-2019-322702

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MeSH Terms: Dementia, Eye Diseases, Hallucinations, Humans, Nervous System Diseases, Parkinson Disease