Visual Hallucinations in Long-Term Care: Page 4 of 4

February 13, 2012


Visual hallucinations are common in older patients, especially those in the LTC setting. The differential diagnosis of visual hallucinations is broad and frequently complicated by difficulty obtaining the patient’s full cooperation in providing a clear history of symptoms due to fears of receiving a psychiatric diagnosis or of developing dementia. A wide variety of medical problems are known to cause visual hallucinations, including psychiatric, neurologic, iatrogenic, metabolic, and ophthalmologic disorders. Visual hallucinations can be the first sign of delirium stemming from a potentially life-threatening yet undetected condition and should be taken seriously. Early diagnosis and treatment of the underlying cause of visual hallucinations can be lifesaving in some cases. Prompt and accurate diagnosis is especially important for older adults, to prevent the risks of polypharmacy or complications associated with inappropriate management approaches, such as restraints, deconditioning, and social isolation.


The authors report no relevant financial relationships.



1. Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual hallucinations in the visually impaired: the Charles Bonnet syndrome. Surv Ophthalmol. 2003;48(1):58-72.

2. Jacob A, Prasad S, Boggild M, Chandratre S. Charles Bonnet syndrome—elderly people and visual hallucinations. BMJ. 2004;328(7455):1552-1554.

3. Gilmour G, Schreiber C, Ewing C. An examination of the relationship between low vision and Charles Bonnet syndrome. Can J Ophthalmol. 2009;44(1):49-52.

4. Schadlu AP, Schadlu R, Shepherd JB. Charles Bonnet syndrome: a review. Curr Opin Ophthalmol. 2009;20(3):219-222.

5. Teeple RC, Caplan JP, Stern TA. Visual hallucinations: differential diagnosis and treatment. Prim Care Companion J Clin Psychiatry. 2009;11(1):26-32.

6. Soeda S, Terao T, Nishimura M, Nakamura J, Iwata N. Aging and visual hallucinations in elderly psychiatric outpatients. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28(2):401-404.

7. Barnes J, David AS. Visual hallucinations in Parkinson’s disease: a review and phenomenological survey. J Neurol Neurosurg Psychiatry. 2001;70(6):727-733.

8. Vukicevic M, Fitzmaurice K. Butterflies and black lacy patterns: the prevalence and characteristics of Charles Bonnet hallucinations in an Australian population. Clin Exp Ophthalmol. 2008;36(7):659-665.

9. Scott IU, Schein OD, Feuer WJ, Folstein MJ. Visual hallucinations in patients with retinal disease. Am J Ophthalmol. 2001;131(5):590-598.

10. Holroyd S. Visual hallucinations in a geriatric psychiatry clinic: prevalence and associated psychiatric diagnoses. J Geriatr Psychiatry Neurol. 1996;9(4):171-175.

11. Ropacki SA, Jeste DV. Epidemiology of and risk factors for psychosis of Alzheimer’s disease: a review of 55 studies published from 1990 to 2003. Am J Psychiatry. 2005; 162(11):2022-2030.

12. Stewart JT. Behavioral and emotional complications of neurologic disorders. In: Noseworthy JH, ed. Neurological Therapeutics: Principles and Practice. 2nd ed. Abingdon, UK: Informa Healthcare, 2006:3207-3222.

13. Gómez-Tortosa E, Ingraham AO, Irizarry MC, Hyman BT. Dementia with Lewy bodies. J Am Geriatr Soc. 1998;46(11):1449-1458.

14. Jackson ML, Ferencz J. Charles Bonnet syndrome: visual loss and hallucinations. CMAJ. 2009;181(3-4):175-176.

15. Francis J. Delirium in older patients. J Am Geriatr Soc. 1992;40(8):829-838.

16. Sandberg O, Gustafson Y, Brännström B, Bucht G. Clinical profile of delirium in older patients. J Am Geriatr Soc. 1999;47(11):1300-1306.

17. Wartenberg AA, Nirenberg TD. Alcohol and other drug abuse in older patients. In: Reichel W, Gallo JJ, Busy-Whitehead J, Delfs JR, Murphy JB, eds. Care of the Elderly: Clinical Aspects of Aging. 4th ed. Baltimore, MD: Williams & Wilkins, 1995:133-141.

18. Dewi Rees W. The hallucinations of widowhood. Br Med J. 1971;4(5778):37-41.

19. Teunisse RJ, Cruysberg JR, Hoefnagels WH, Verbeek AL, Zitman FG. Visual hallucinations in psychologically normal people: Charles Bonnet’s syndrome. Lancet. 1996;347(9004):794-797.

20. Ricard P. Vision loss and visual hallucinations: the Charles Bonnet syndrome. Community Eye Health. 2009;22(69):14.

21. Hartney KE, Catalano G, Catalano MC. Charles Bonnet syndrome: are medications necessary? J Psychiatr Practice. 2011;17(2):137-141.

22. Gold K, Rabins PV. Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry. 1989; 30(1):90-98.

23. Cole MG. Charles Bonnet hallucinations: a case series. Can J Psychiatry. 1992; 37(4):267-270.

24. Rovner BW. The Charles Bonnet syndrome: a review of recent research. Curr Opin Ophthalmol. 2006;17(3):275-277.

25. Ffytche DH. Visual hallucinations in eye disease. Curr Opin Neurol. 2009;22(1):28-35.

26. Kolmel HW. Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry. 1985;48(1):29-38.

27. Santhouse AM, Howard RJ, Ffytche DH. Visual hallucinatory syndromes and the anatomy of the visual brain. Brain. 2000;123(Pt 10):2055-2064.

28. Manford M, Andermann F. Complex visual hallucinations: clinical and neurobiological insights. Brain. 1998;121(Pt 10):1819-1840.

29. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

30. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.

31. Schneider LS. Pharmacologic management of psychosis in dementia. J Clin Psychiatry. 1999;60(suppl 8):54-60.

32. Karim S, Byrne EJ. Treatment of psychosis in elderly people. Advances in Psychiatric Treatment. 2005;11:286-296.

33. Thorpe L. Treatment of psychiatric disorders in late life. Can J Psychiatry. 1997;42(suppl 1):19S-27S.

34. Ballard C, Grace J, McKeith I, Holmes C. Neuroleptic sensitivity in dementia with Lewy bodies and Alzheimer’s disease. Lancet. 1998;351(9108):1032-1033.

35. Ukai S, Yamamoto M, Tanaka M, Takeda M. Treatment of typical Charles Bonnet syndrome with donepezil. Int Clin Psychopharmacol. 2004;19(6):355-357.

36. Hosty G. Charles Bonnet syndrome: a description of two cases. Acta Psychiatr Scand. 1990;82(4):316-317.

37. Stewart JT, Yelton JA. Treatment of organic hallucinosis with carbamazepine. Am J Psychiatry. 1995;152(1):150.

38. Hori H, Terao T, Shiraishi Y, Nakamura J. Treatment of Charles Bonnet syndrome with valproate. Int Clin Psychopharmacol. 2000;15(2):117-119.

39. Paulig M, Mentrup H. Charles Bonnet’s syndrome: complete remission of complex visual hallucinations treated by gabapentin. J Neurol Neurosurg Psychiatry. 2001;70(6):813-814.

40. Zoldan J, Friedberg G, Livneh M, Melamed E. Psychosis in advanced Parkinson’s disease: treatment with ondansetron, a 5-HT3 receptor antagonist. Neurology. 1995;45(7):1305-1308.