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

Workforce Competencies and Training Issues

As familiar and trusted advisors, primary care physicians can play a critical role in the early phases of assessment and treatment of hallucinations in older adults by: debunking myths and stereotypes (eg, that everyone who hallucinates has a psychotic disorder), providing relevant facts about hallucinations (eg, that distress associated with hallucinations can be treated), liaising with the client's primary and specialist care network, and arranging referral (eg, when trauma or bereavement are central factors in distressing hallucinations). However, hallucinations are also reported in general hospital admissions,[20,21] emergency departments,[22] routine healthcare appointments, and by residents in long-term care.[23] Consequently, staff in all these settings need up-to-date knowledge and skills to offer optimal care and support that fits the client's needs.

Client-centered Factors

Both complex and simple hallucinations can be a cause of considerable disruption to daily life (eg, aggressive behavior, falls, social withdrawal) and distress. For example, tinnitus—the experience of a persistent sound in the absence of an external source—can provoke anxiety, loneliness, and anger.[24] Similarly, hallucinations associated with postoperative delirium can be highly distressing and may contribute to the development of post-traumatic stress disorder.[25] These negative responses can be exacerbated by unhelpful interactions with the treating team (eg, when clinicians convey a lack of hope). Similarly, people with dementia and Parkinson's disease may show an initial phase of uncertainty and distress when hallucinations first begin, which abates when patients learn that the experiences are not real.[26] It is important to recognize, however, that hallucinations are relatively common in "healthy" older adults (ie, in the absence of psychotic disorder or dementia[8,16]) and are not necessarily distressing. For example, in Charles Bonnet syndrome, a variety of positive emotional responses (amusement, curiosity) have been reported.[27] That said, the role of emotions in hallucinations is often complex. For instance, older people who are lonely may be fearful that the treatment team will "take them away from them"—depriving them of the sense of social connection that hallucinations sometimes provide. Similarly, bereavement hallucinations, which are a common reaction after a loss, are not only often regarded as positive,[17,28,29] but are also associated with higher levels of depression, anxiety, and clinically impairing grief.[17,30]

Culture also has a significant influence on the meaning, content, and expression of hallucinations—as well as with beliefs about treatment.[31,32] Voice-hearing experiences tend to be viewed as more negative and threatening in high-income countries and more benign in low- or middle-income countries.[33] Consequently, official guidelines and training programs now include cultural diversity as part of competency-based curricula,[34] and developing culturally safe practice is considered particularly important when working with indigenous people, First Nations, Native peoples, or Aboriginal and Torres Strait Islander communities in Australia.[35]

Negative stereotypes about hallucinations can hinder the disclosure of these experiences, leading to delays in accessing help.[26,36] For instance, hallucinations are often considered synonymous with psychotic disorder, which is frequently stereotyped in terms of dangerousness and incompetence. As a result, older adults with hallucinations are often concerned that they are becoming mentally ill or developing dementia and worry about how treating clinicians will respond.[37] Concerns about social disapproval can also lead to the same perceptual experience being described quite differently in different contexts.[38] As a general point, adopting the terminology that older adults use when describing their experiences can often help the clinician to gain a better insight into their client's understanding of hallucinations.

Practitioner-centered Factors

Low levels of knowledge about aging and hallucinations remain an ongoing issue amongst many professionals.[39] For example, some ophthalmologists and general practitioners remain unfamiliar with visual hallucinations arising from eye disease (ie, Charles Bonnet syndrome)—and consequently rarely discuss the possibility of hallucinatory experiences in patients with visual loss.[27,37,40] Similarly, auditory hallucinations are common in people with hearing impairment, which suggests that clinicians should enquire about hallucinations in hearing-impaired patients and assess hearing ability in older people with recent-onset auditory hallucinations.[12]

Biased thinking about hallucinations can also occur, despite the good intentions of staff to help their clients/patients. For example, fear that people with hallucinations might be dangerous may lead to less willingness to discuss voice-hearing experiences with patients.[41] In general, negative stereotypes have been shown to be associated with less focus on the patient (than the disease), lower endorsement of recovery as an outcome of care, and fewer referrals for specialist treatment[42] (see also reference[43]). Consequently, a growing number of programs are being trialed that promote stigma reduction and supportive, nonjudgmental attitudes toward hallucinations in healthcare professionals and students[44] (see Table 2).

Finally, it is important for clinicians to think about the needs of the caregivers as well as the patient. For example, informal caregivers can find managing visual hallucinations in Parkinson's challenging, which can have a negative impact on their quality of life.[26] Consequently, the focus of "treatment" sometimes must shift from the person experiencing hallucinations to providing psychoeducation (eg, about causes of hallucinations) and support (eg, coping methods) for the person who cares for them.