Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management

Author:

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

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.

Funder

Programme Grants for Applied Research

Publisher

BMJ

Subject

Psychiatry and Mental health,Neurology (clinical),Surgery

Reference91 articles.

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