1 Hallucinations in Hallucinations in the Elderly the Elderly Dr. Lisa McMurray, MD, FRCPC Dr. Lisa McMurray, MD, FRCPC Geriatric Psychiatry Program Geriatric Psychiatry Program Royal Ottawa Mental Health Centre Royal Ottawa Mental Health Centre Assistant Professor, University of Ottawa Assistant Professor, University of Ottawa Objectives Objectives Recognize a hallucination in an elderly patient Use the characteristics of a hallucination to inform diagnosis Manage hallucinations using psychosocial and environmental strategies Propose a medication to treat hallucinations in an elderly patient
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Hallucinations in Hallucinations in the Elderlythe Elderly
Dr. Lisa McMurray, MD, FRCPCDr. Lisa McMurray, MD, FRCPCGeriatric Psychiatry ProgramGeriatric Psychiatry Program
Royal Ottawa Mental Health CentreRoyal Ottawa Mental Health CentreAssistant Professor, University of OttawaAssistant Professor, University of Ottawa
ObjectivesObjectivesRecognize a hallucination in an elderly patient
Use the characteristics of a hallucination to inform diagnosis
Manage hallucinations using psychosocial and environmental strategies
Propose a medication to treat hallucinations in an elderly patient
2
HallucinationsHallucinationsFalse sensory experiencesSeem real Generated by the mindNo external stimulusmay be
seen (visual)heard (auditory)felt (tactile)smelled (olfactory)tasted (gustatory)
IllusionsIllusionsDistorted perceptionsBased on a real external stimulusE.g. waving curtain appears as a menacing faceMost characteristic of delirium
3
Is this a hallucination?Is this a hallucination?Consider illusions (e.g. reflection in mirror)Consider errors of language (e.g. person names an object inaccurately)Consider errors of time perception time perception
DelusionDelusionFixed, false beliefCan be associated with hallucinations (but not always)E.g. My husband is cheating on me.
4
Which of the following are Which of the following are Hallucinations?Hallucinations?
A. I smell burnt toastB. My neighbour is stealing from meC. I see flies all over my wall (points to marks on
wall)D. I heard my dead husband calling meE. My wife is not my real wife, she’s an imposter
Which of the following are Which of the following are Hallucinations?Hallucinations?
A. I smell burnt toast [olfactory hallucination]B. My neighbour is stealing from me [delusion]C. I see flies all over my wall (points to marks on
wall) [illusion]D. I heard my dead husband calling me
[auditory hallucination]E. My wife is not my real wife, she’s an imposter
[delusion]
5
What Causes Hallucinations?What Causes Hallucinations?DeliriumDementiaPsychiatric Illnesses
Depression, mania, schizophreniaGeneral medical conditionsSubstance Use/WithdrawalMedicationsSensory impairment
In short, almost everything!
Pathophysiology of hallucinationsPathophysiology of hallucinationsAny lesion causing excitation in the sensory pathways or association cortexLoss of sensory input can produce disinhibition in the sensory pathways, causing hallucinationsLesions affecting the attentional system in the brainstem
6
Rules of thumb…Rules of thumb…Auditory hallucinations
Characteristic of psychiatric illnessCommonly seen in Alzheimer’s dementia
Visual hallucinationsSuggest a non-psychiatric etiologyDelirium, Lewy Body Dementia
TactileSuggest substance use/withdrawal
Olfactory and Gustatory hallucinationsSuggest medical etiology
There are many exceptions!
Mrs. A.Mrs. A.93 yo woman6 months of auditory hallucinationsTrials of Donepezil (Aricept), Olanzapine (Zyprexa), Risperidone (Risperdal) not tolerated or ineffectiveCurrent medications:
Other drugs associated with hallucinationsOther drugs associated with hallucinationsAntidepresantsTramadol and other opiatesQuinolonesProton pump inhibitorsClarithromycinZopicloneRopinirole and other dopaminergic agentsBeta agonistsOpiates
Drug-induced hallucinations can be unformed (e.g. abstract shapes, flashes, bangs, whistles, thuds) or complex (e.g. images, music)
Review the medsReview the medsRationalizing an elder’s
medication list is one of the most powerful interventions we have!
10
DeliriumDelirium
An acute, potentially reversible, confusional state
Associated with impaired attention/level of consciousness
DeliriumDeliriumKey Features
Change from usual mental state!!!Fluctuates (may appear normal at times)Altered level of consciousness (hyper/hypo or mixed)Inattention (you must repeat questions because patients attention wanders)Perceptual disturbances (visual hallucinations and paranoid delusions)Disorganized thinking (rambling, tangential speech)
Psychomotor changes (hyper or hypoactive)
11
Delirium is seriousDelirium is seriousPatients with delirium have:- prolonged length of stay in hospital- worse rehabilitation/functional outcomes- higher institutionalization rates- increased risk of cognitive decline- higher mortality ratesDelayed recognition → worse outcomes
Typical Hallucinations of DeliriumTypical Hallucinations of DeliriumOften visual
Can be complex, e.g. snake in hospital roomOften distorted or frightening
Tactile, auditory are possible as well
12
Look for the underlying causeLook for the underlying causeMedications are common culprits (up to 40%)The underlying cause is often not found (15-20%)
Hallucinations and substance use Hallucinations and substance use Alcohol and prescription drugs are most commonHallucinations can occur in intoxication, withdrawal, and in chronic useAlcohol withdrawal delirium is a medical emergency
Thiamine, benzodiazepines, admission
13
Hallucinations in Psychiatric IllnessesHallucinations in Psychiatric IllnessesAuditory most commonOften critical or pejorativeSmall percentage of schizophrenia has onset after age 50If present in depression:
Psychotic depression is poorly responsive to medsConsider electroconvulsive therapy (ECT)
Charles Bonnet Charles Bonnet SyndromeSyndrome-complex visual hallucinations in a psychologically normal person
-his 87-year-old grandfather, who was nearly blind from cataracts, saw people, birds, carriages, buildings, tapestries and scaffolding patterns
-no treatment required if non-distressing
-analogous to tinnitus and musical hallucinations in severe hearing loss
Types of dementia clinically diagnosed in Canadian memory clinics
Common Dementias and their Common Dementias and their HallucinationsHallucinations
Alzheimer’s DementiaDementia with Lewy BodiesVascular DementiaFrontotemporal Dementia
15
Alzheimer’s and HallucinationsAlzheimer’s and HallucinationsPrevalence
25% of patients4-76%, median 23%Visual 4-59%, median 19%Auditory 1-29%, median 12%Other types 0.5-8%, median 4%
Bassiony M, et al, 2003
Alzheimer’s and HallucinationsAlzheimer’s and HallucinationsTiming and Course
Rarely manifest early in the illnessOverall prevalence increases slowly with dementia progressionOnce present, they frequently recur
Bassiony, M et al, 2003
16
LewyLewy Body Dementia and HallucinationsBody Dementia and HallucinationsMay account for up to 20% of late-onset dementiaComplex, well-formed visual hallucinations common in early stagesContinuum with Parkinson’s Neuroleptic sensitivity in 50%
Other DementiasOther DementiasHallucinations are not characteristic of vascular dementia but can occur in some casesHallucinations are more rare in fronto-temporal dementia
17
TreatmentTreatmentAccurate assessment
Really a hallucination?Who/what/where/when?Persistent?Significant Distress?
Psychotic symptoms are prevalent above age 85 (10%) and do not always require treatment
Correct vision and hearingCorrect vision and hearingClean glassesRight prescriptionRepair cataractsHearing aids, working and properly installed
18
Treatment Treatment ----EnvironmentalEnvironmental Adequate lightingAdequate lighting can be a problem in many settings
Improved lighting reduces visual hallucinations
Eliminate shadows, busy patterns
Mirrors and TVs may trigger misperceptions
Eunice Noel-Wagonner, Center of Design for an Aging Society
Treatment Treatment -- PsychosocialPsychosocialPersonalized music/headphones/IPodSocial contact and conversationPrayer and singingEarplug in one ear
May be particularly effective in LewyBody/Parkinson’s dementia, in which there is a profound anticholinergic deficitAlzheimer and Vascular, first line because of low harm and impact on underlying illnessNo efficacy in Frontotemporal
Caution: neuroleptic sensitivity in Lewy Body Dementia 50% of these patients may have severe reactions with increased mortalityIn other dementias, 1.7% increased risk of stroke, deathWeigh risks and benefits
Anticonvulsants (e.g. Gabapentin)Anecdotal evidence in particular cases, especially in context of sensory impairment
20
Antipsychotics for hallucinationsAntipsychotics for hallucinationsIndicated for major psychiatric illnesses
Keep using them!only modest efficacy in agitation/psychosis in dementia (e.g. 40% reduction in symptoms)
No drug has FDA indicationShort-term efficacy – but symptoms persist!
Constipation! Akathisia (agitation)Extrapyramidal symptomsTardive dyskinesiaSedationOrthostatic hypotensionWeight gain
diabeteshyperlipidemia
21
Antipsychotics to considerAntipsychotics to considerRisperidone
Significant ParkinsonismRapidly dissolving tablet available
OlanzapineWeight gain and diabetesMay be particularly bad for Lewy Body and neuroleptic sensitivityRapidly dissolving tablet, short-acting injection available
AripiprazoleSome evidence for effectiveness, possibly not as robustWeak partial agonist at D2 receptorDopamine-serotonin system stabilizerlow weight gain
QuetiapineLow D2 blockade, but sedatingLimited evidence for effectiveness
ClozapineParticularly effective in Parkinson’sNo D2 blockadeLow doses often effectiveAgranulocytosis, sedating, anticholinergic, weekly blood monitoriingProbably underused but significant toxicity
BBottom Line for ottom Line for Hallucinations in DementiaHallucinations in DementiaDrugs are modestly effective and carry significant riskConsider non-pharmacological interventionConsider risks of not treatingInformed consentAttempt to discontinue periodically
22
ObjectivesObjectivesRecognize a hallucination in an elderly patient
Use the characteristics of a hallucination to inform diagnosis
Manage hallucinations using psychosocial and environmental strategies
Propose a medication to treat hallucinations in an elderly patient