An elderly with Complex Visual Hallucinations, a case report.

A case report published by Francesca Hill et al. in Hindawi Journal, reports the challenging case of an elderly suffering from frightening complex visual hallucinations; the diagnosis was ultimately determined to be an unusual manifestation of vascular dementia.

Visual hallucinations (VH) in the elderly can be caused by a diverse range of conditions. These range from neurodegenerative conditions (particularly Lewy Body dementia as well as other forms of dementia), Charles Bonnet Syndrome (CBS), delirium, and psychiatric conditions including schizophrenia. VH in the visually impaired often prompts a diagnosis of CBS, especially when the hallucinations are of a complex nature.

The criteria laid out by Teunisse et al. Shown in table 1 should be fulfilled in order to diagnose a patient with CBS. The ICD-11 is set to include CBS (which it terms "visual release hallucinations"); it is worth noting that there will be no criterion for retained insight. The ICD-11 does state that "hallucinations are exclusively visual, usually temporary, and unrelated to mental or behavioural disorders".

However, when the insight is found to be lacking, a diagnosis of dementia should be considered. Dementia, including Alzheimer's disease, commonly presents with VH. It was found 19% that of patients with Alzheimer's presented with VH which is a greater proportion compared to Alzheimer's patients experiencing auditory hallucinations,12%. Complex visual hallucinations are also considered a key component of dementia with Lewy Bodies (DLB) and are estimated to occur in roughly 25% of patients with Parkinson's disease. There has been comparatively less research into VH in the context of vascular dementia, and estimates of the prevalence of VH in the condition vary widely.

A lady in the early 90's presented with a range of hallucinations which she found immensely distressing. An experienced distressing VH that included monkeys ripping the heads off her cats and lions prowling in the garden and sleeping on the roof. She lacked insight, believing that the animals had escaped from her neighbors' house. She engaged in risky behaviors, which included her trying to take control of the car whilst her daughter was driving in an attempt to avoid a VH of an unknown nature and wandering from the house, requiring her to be brought back by the police. The hallucinations had been present for over a year. Some unusual behaviours included referring to her granddaughter (a woman of roughly 40 years of age) as "Dorothy Powers," saying that she is a very frail elderly lady. There were occasions where Mrs. A had appeared to be experiencing auditory hallucinations; this included reported hearing gramophone music playing in the distance. After ophthalmological examination, the patient was seen to be suffering from various pathologies which included cataracts, a branch retinal vein occlusion, and vitreous haemorrhage. Surgeries were advised for the same. There is also a history of TIA 2 years back that caused LOC & was on medication for anxiety (Flunazepam 15mg). CO-morbidity included- hypertension, diverticulitis & vitamin D deficiency.

The patient was started on olanzapine 2.5mg which did relieve the symptoms while 5mg caused sedation.

Meanwhile, the ophthalmological procedure took place 5 months after the patient was reviewed. It involved 3 procedures. Family members reported a "marked decrease" in VH. However, she stated that the monkeys had "gone next door." Her belief that the monkeys had been present in the garden remained intact. On completing her cognitive testing, it was favoring that dementia has been present in the patient. The patient's misidentification of her granddaughter and wandering are evidence that dementia had been present. The patient underwent CT head demonstrated cognitive impairment, thus the diagnosis of dementia was made; the dementia was deemed to be likely vascular in nature due to the appearances on imaging. Memantine 5mg was added, which was later stopped by the family members as it was causing sedation. There was no evidence of motor involvement, no tremor was detectable and there was no micrographics which ruled out the diagnosis of Lewi body dementia. Diagnosis of CBS was ruled out as (Teunisse checklist):

- Lack of insight into the hallucinatory nature of her experiences,

- the absence of hallucinations in other modalities (note the presence of auditory hallucinations), and

- the absence of delusions (which she displayed through her bizarre and unshakeable belief that her granddaughter was an elderly lady named Dorothy Powers).

As with CBS, visual acuity in dementia plays a key role in the development of VH. Further, correction of visual deficits can lead to the resolution of VH in dementia patients. The presence of vascular dementia was further evidence against the diagnosis of CBS given that vascular dementia itself is associated with VH.

Source: Hindawi journal: Francesca Hill, Matthew Spurr, Joseph Stratford, "Frightening Complex Visual Hallucinations in an Elderly Patient with Ophthalmological Pathology and Vascular Dementia", Case Reports in Psychiatry, vol. 2020, Article ID 8851761, 5 pages, 2020. https://doi.org/10.1155/2020/8851761