Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management

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

doi:10.1136/jnnp-2019-322702

Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management

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

Research output: Contribution to journal › Review article › peer-review

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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.

Original language	English
Article number	322702
Pages (from-to)	512-519
Number of pages	8
Journal	Journal of Neurology, Neurosurgery and Psychiatry
Volume	91
Issue number	5
Early online date	25 Mar 2020
DOIs	https://doi.org/10.1136/jnnp-2019-322702 https://doi.org/10.1136/jnnp-2019-322702
Publication status	Published - 1 May 2020

Keywords

dementia
hallucinations
parkinson's disease

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Visual hallucinations in neurological_O'BRIEN_Acc21Feb2020Epub25Mar2020_GOLD VoR(CC BY)Final published version, 665 KBLicence: CC BY

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O'Brien, J., Taylor, J. P., Ballard, C., Barker, R. A., Bradley, C., Burns, A., Collerton, D., Dave, S., Dudley, R., Francis, P., Gibbons, A., Harris, K., Lawrence, V., Leroi, I., McKeith, I., Michaelides, M., Naik, C., O'Callaghan, C., Olsen, K., ... Ffytche, D. (2020). Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management. Journal of Neurology, Neurosurgery and Psychiatry, 91(5), 512-519. Article 322702. https://doi.org/10.1136/jnnp-2019-322702, https://doi.org/10.1136/jnnp-2019-322702

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title = "Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management",

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.",

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O'Brien, J, Taylor, JP, Ballard, C, Barker, RA, Bradley, C, Burns, A, Collerton, D, Dave, S, Dudley, R, Francis, P, Gibbons, A, Harris, K, Lawrence, V, Leroi, I, McKeith, I, Michaelides, M, Naik, C, O'Callaghan, C, Olsen, K, Onofrj, M, Pinto, R, Russell, G, Swann, P, Thomas, A, Urwyler, P, Weil, RS & Ffytche, D 2020, 'Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management', Journal of Neurology, Neurosurgery and Psychiatry, vol. 91, no. 5, 322702, pp. 512-519. https://doi.org/10.1136/jnnp-2019-322702, https://doi.org/10.1136/jnnp-2019-322702

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AU - O'Brien, John

AU - Taylor, John Paul

AU - Ballard, Clive

AU - Barker, Roger A.

AU - Bradley, Clare

AU - Burns, Alistair

AU - Collerton, Daniel

AU - Dave, Sonali

AU - Dudley, Rob

AU - Francis, Paul

AU - Gibbons, Andrea

AU - Harris, Kate

AU - Lawrence, Vanessa

AU - Leroi, Iracema

AU - McKeith, Ian

AU - Michaelides, Michel

AU - Naik, Chaitali

AU - O'Callaghan, Claire

AU - Olsen, Kirsty

AU - Onofrj, Marco

AU - Pinto, Rebecca

AU - Russell, Gregor

AU - Swann, Peter

AU - Thomas, Alan

AU - Urwyler, Prabitha

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AB - 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.

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Visual hallucinations in neurological and ophthalmological disease: Pathophysiology and management

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Keywords

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