Schizophrenia Bulletin

doi:10.1093/schbul/sbaa073

Hallucinations in Older Adults: A Practical Review

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Johanna C. Badcock*,1,2, Frank Larøi3–5, Karina Kamp6, India Kelsall-Foreman1, Romola S. Bucks1, Michael Weinborn1,
Marieke Begemann8, John-Paul Taylor9, Daniel Collerton9, John T. O’Brien10, , Mohamad El Haj11, Dominic ffytch12,
and Iris E Sommer7
1
School of Psychological Science, University of Western Australia, Perth 6009, Australia; 2Perth Voices Clinic, Murdoch 6150, Australia;
3
Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway; 4Psychology and Neuroscience of Cognition
Research Unit, University of Liege, Liege, Belgium; 5Norwegian Centre of Excellence for Mental Disorders Research, University of
Oslo, Oslo, Norway; 6Department of Psychology and Behavioural Science, Aarhus University, Aarhus C, DK 8000, Denmark; 7Rijks
Universiteit Groningen (RUG), Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, The
Netherlands; 8Department of Biomedical Sciences of Cells and Systems, University Medical Center, Rijks Universiteit Groningen
(RUG), Groningen, The Netherlands; 9Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK;
10
Department of Psychiatry, University of Cambridge, Cambridge, UK; 11Laboratoire de Psychologie des Pays de la Loire (LPPL-EA
4638), Nantes Université, Univ Angers, F-44000 Nantes, France; 12Department of Old Age Psychiatry, Institute of Psychiatry,
Psychology and Neuroscience, King’s College, London, UK
*To whom correspondence should be addressed; School of Psychological Science, The University of Western Australia, 35 Stirling
Highway, Perth, 6009; tel: 0423123665, fax: 61864881006, e-mail: johanna.badcock@uwa.edu.au

Older adults experience hallucinations in a variety of so- these experiences in their workplace. Hallucinations
cial, physical, and mental health contexts. Not everyone can be defined as “a perception-like experience with
is open about these experiences, as hallucinations are sur- the clarity and impact of a true perception but without
rounded with stigma. Hence, hallucinatory experiences the external stimulation of the relevant sensory organ” 2
in older individuals are often under-recognized. They are (cf. 3–5), though this belies the difficulty in discerning the
also commonly misunderstood by service providers, sug- boundaries between normal and abnormal perception.6
gesting that there is significant scope for improvement in Hallucinations need to be distinguished from illusions,
the training and practice of professionals working with which are perceptual experiences in which an external
this age group. The aim of the present article is to increase stimulus is misperceived or misinterpreted.2 In practice,
knowledge about hallucinations in older adults and provide hallucinations vary in content (eg, perception of people,
a practical resource for the health and aged-care work- animals, or objects), character (eg, frequency, emotional
force. Specifically, we provide a concise narrative review valence, location), duration (from seconds to chronically
and critique of (1) workforce competency and training is- present), complexity (eg, perception of simple stimuli vs
sues, (2) assessment tools, and (3) current treatments and organized scenes or objects), and quality (eg, perceived
management guidelines. We conclude with a brief summary reality, intrusiveness) and occur in all sensory modalities.
including suggestions for service and training providers and The terms used to refer to hallucinations are equally di-
future research. verse (see table 1).
Hallucinations occur in people with sensory, neurolog-
Key words: hallucinations/assessment/treatment/older ical, medical, neurodegenerative, and psychological dis-
adults/training/aged-care orders7 as well as in those with no mental disorder at all.8–10
In healthy (nonclinical) samples, hallucination prevalence
(across modalities) is lower in older than younger adults.8,9
General Introduction
In contrast, hallucinations are common in many clinical
By 2050, it is estimated that 16% of people will be aged disorders associated with older age, with specific prevalence
above 65 years, compared with 9% in 2019.1 Population rates varying by condition, stage of illness, and symptom
aging is driving increased attention to the physical and type. For example, visual hallucinations are common in de-
mental health needs of older adults. Here, our focus is mentia, Parkinson’s disease, and in eye or visual pathway
on hallucinations—given the wide range of health and disease,11 while auditory hallucinations are prevalent with
aged-care service providers who encounter people with hearing loss.12 Similarly, multimodal visual, tactile, and

© The Author(s) 2020. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.
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J. C. Badcock et al

Table 1. Key Terms and Definitions of Hallucinations

Type of Hallucina-
tion Related Terms Definition

Bereavement hallu- ➢ Grief hallucinations The experience of seeing, hearing, feeling, tasting, smelling, and/
cinations ➢ Sensed presence or sensing the presence of the deceased.

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➢ Experience of continued presence
➢ Guardian angel experience
Charles Bonnet syn- ➢ “Phantom vision” syndrome Typically involves the experience of complex (ie, formed) visual
drome hallucinations, in the context of visual loss, with insight that the
experience is not real, in people with no marked cognitive
dysfunction.
Complex hallucin- The involuntary perception of an object or scene in the absence of
ations a corresponding object/scene in the environment (ie, a formed
perception whereby individual features have been linked or
grouped into organized/connected wholes).
Hallucinations ➢ Private perceptions “A sensory experience which occurs in the absence of corre-
➢ Hearing voices (in the case of auditory sponding external stimulation of the relevant sensory organ; has a
hallucinations) sufficient sense of reality to resemble a veridical perception, over
➢ Seeing visions (in the case of visual which the subject does not feel s/he has direct voluntary control
hallucinations) and which occurs in the awake state.” 3
➢ Unusual sensory experiences “an erroneous percept in the absence of identifiable stimuli.” 4
➢ Anomalous perceptions “[Perceiving] something involuntarily which, by all other
measures, is not there.” 5
Hypnogogic and ➢ Sleep-related hallucinations Vivid, dreamlike experiences that occur on the borders of sleep
hypnopompic These anomalous perceptions can occur when falling asleep
hallucinations (hypnogogic) or waking up (hypnopompic).
Multimodal ➢ Compound hallucinations Hallucinations that occur in more than one modality
hallucinations ➢ Polymodal hallucinations simultaneously, typically emanating from a single source. NB.
➢ Polysensual hallucinations Sometimes refers to hallucinations in different sensory modalities
➢ Intersensorial hallucinations experienced serially.
Musical ➢ Musical hallucinosis The subjective experience of hearing music, or aspects of music,
hallucinations ➢ Musical ear syndrome when none is being played. The perception of music can occur
➢ Auditory Charles Bonnet syndrome with or without voice and lyrics.
➢ Oliver Sack’s syndrome
Olfactory ➢ Phantosmia The detection of smells, when the corresponding odor is not
hallucinations ➢ Phantom smells present in the environment.
Passage ➢ Sometimes referred to as The experience of a stimulus moving past the perceiver, in the
hallucinations “minor hallucinations” periphery.
Presence ➢ Feeling of presence The vivid sensation of the presence of another person or agent,
hallucinations ➢ Sensed presence usually close by, or just behind, the perceiver.
Simple The perception of unformed stimuli (eg, colored lines,
hallucinations high-pitched tones), when there are no such stimuli in the
environment (ie, perceptions involving specific stimulus features
rather than whole objects).
Tactile ➢ Hallucinations of touch The perception of a tactile stimulus that is not explained by the
hallucinations actions of another person or external object
Tinnitus ➢ Often called “ringing in the ears” The perception of noises in one or both ears or inside the head,
when no external sound source is present. Sounds often involve
ringing, hissing, whistling, or buzzing but can be more complex
(eg, a familiar tune).

auditory hallucinations tend to be more prominent in communicating these advances to clinicians so that clinical
late- (between 40 and 60 years age) or very-late onset (60+ care can be grounded in the best available evidence. The
years) compared with early-onset schizophrenia.13 Across International Consortium of Hallucinations Research
conditions, both similarities and differences have been re- Working Group on Hallucinations in Older Adults was
ported,14,15 suggesting that the same assessments and treat- set up to respond to this challenge. Accordingly, the pur-
ments may not be appropriate for all presentations of pose of this review is to highlight the key issues for the
hallucinations in older adults, which may be linked to the workforce caring for older adults with hallucinations;
diversity of risk factors involved.16–19 critically review current assessment tools, management
Whilst our understanding, assessment, and treat- guidelines, and treatment approaches for this population;
ment of hallucinations in older adults have improved and offer recommendations and resources to support
in the last decade, greater priority needs to be given to best practice.
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 Hallucinations and Ageing

Workforce Competencies and Training Issues middle-income countries.33 Consequently, official guide-
lines and training programs now include cultural diversity
As familiar and trusted advisors, primary care phys-
as part of competency-based curricula,34 and developing
icians can play a critical role in the early phases of as-
culturally safe practice is considered particularly impor-
sessment and treatment of hallucinations in older adults
tant when working with indigenous people, First Nations,
by: debunking myths and stereotypes (eg, that everyone
Native peoples, or Aboriginal and Torres Strait Islander
who hallucinates has a psychotic disorder), providing rel-
communities in Australia.35

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evant facts about hallucinations (eg, that distress asso-
Negative stereotypes about hallucinations can hinder
ciated with hallucinations can be treated), liaising with
the disclosure of these experiences, leading to delays in
the client’s primary and specialist care network, and ar-
accessing help.26,36 For instance, hallucinations are often
ranging referral (eg, when trauma or bereavement are
considered synonymous with psychotic disorder, which is
central factors in distressing hallucinations). However,
frequently stereotyped in terms of dangerousness and in-
hallucinations are also reported in general hospital ad-
competence. As a result, older adults with hallucinations
missions,20,21 emergency departments,22 routine health-
are often concerned that they are becoming mentally ill
care appointments, and by residents in long-term care.23
or developing dementia and worry about how treating
Consequently, staff in all these settings need up-to-date
clinicians will respond.37 Concerns about social disap-
knowledge and skills to offer optimal care and support
proval can also lead to the same perceptual experience
that fits the client’s needs.
being described quite differently in different contexts.38
As a general point, adopting the terminology that older
Client-Centered Factors adults use when describing their experiences can often
help the clinician to gain a better insight into their client’s
Both complex and simple hallucinations can be a cause understanding of hallucinations.
of considerable disruption to daily life (eg, aggressive be-
havior, falls, social withdrawal) and distress. For example,
tinnitus—the experience of a persistent sound in the ab- Practitioner-Centered Factors
sence of an external source—can provoke anxiety, lone- Low levels of knowledge about aging and hallucinations
liness, and anger.24 Similarly, hallucinations associated remain an ongoing issue amongst many professionals.39
with postoperative delirium can be highly distressing and For example, some ophthalmologists and general prac-
may contribute to the development of post-traumatic titioners remain unfamiliar with visual hallucinations
stress disorder.25 These negative responses can be exacer- arising from eye disease (ie, Charles Bonnet syndrome)—
bated by unhelpful interactions with the treating team and consequently rarely discuss the possibility of hal-
(eg, when clinicians convey a lack of hope). Similarly, lucinatory experiences in patients with visual loss.27,37,40
people with dementia and Parkinson’s disease may show Similarly, auditory hallucinations are common in people
an initial phase of uncertainty and distress when hallucin- with hearing impairment, which suggests that clinicians
ations first begin, which abates when patients learn that should enquire about hallucinations in hearing-impaired
the experiences are not real.26 It is important to recognize, patients and assess hearing ability in older people with
however, that hallucinations are relatively common in recent-onset auditory hallucinations.12
“healthy” older adults (ie, in the absence of psychotic dis- Biased thinking about hallucinations can also occur,
order or dementia8,16) and are not necessarily distressing. despite the good intentions of staff to help their clients/
For example, in Charles Bonnet syndrome, a variety of patients. For example, fear that people with hallucin-
positive emotional responses (amusement, curiosity) have ations might be dangerous may lead to less willingness
been reported.27 That said, the role of emotions in hal- to discuss voice-hearing experiences with patients.41 In
lucinations is often complex. For instance, older people general, negative stereotypes have been shown to be as-
who are lonely may be fearful that the treatment team sociated with less focus on the patient (than the disease),
will “take them away from them”—depriving them of lower endorsement of recovery as an outcome of care,
the sense of social connection that hallucinations some- and fewer referrals for specialist treatment42 (see also ref-
times provide. Similarly, bereavement hallucinations, erence 43). Consequently, a growing number of programs
which are a common reaction after a loss, are not only are being trialed that promote stigma reduction and sup-
often regarded as positive,17,28,29 but are also associated portive, nonjudgmental attitudes toward hallucinations
with higher levels of depression, anxiety, and clinically in healthcare professionals and students44 (see table 2).
impairing grief.17,30 Finally, it is important for clinicians to think about
Culture also has a significant influence on the meaning, the needs of the caregivers as well as the patient. For ex-
content, and expression of hallucinations—as well as ample, informal caregivers can find managing visual hal-
with beliefs about treatment.31,32 Voice-hearing experi- lucinations in Parkinson’s challenging, which can have a
ences tend to be viewed as more negative and threatening negative impact on their quality of life.26 Consequently,
in high-income countries and more benign in low- or the focus of “treatment” sometimes must shift from

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J. C. Badcock et al

the person experiencing hallucinations to providing hallucinations modalities and delusions, whereas the
psychoeducation (eg, about causes of hallucinations) and PSYRATS assesses delusions but only auditory hallu-
support (eg, coping methods) for the person who cares cinations.61 Important to note is that the PSYRATS was
for them. developed for the assessment of patients with psychotic
disorder, so it is arguably less suitable for older clinical
Assessment Tools groups where, eg, visual (and other) hallucinations dom-
inate. However, the PSYRATS does show sensitivity

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For the purposes of this review, clinicians and researchers to change and is, therefore, widely used in evaluating
with particular expertise in hallucinations in older popu- the treatment of hallucinations (cf. 70–73). Although the
lations were asked to provide a list of key elements that PSYRATS has been in use for two decades, to the best
underpin high-quality assessment tools as well as features of our knowledge, it has not been systematically inves-
specifically relevant to tools for assessing hallucinations tigated in older populations. Finally, it is still unknown
in older adults (step 1). Thereafter, these same experts if hallucination measures are invariant across samples,
were asked to provide a list of existing assessment tools making comparisons of scores between different samples
for hallucinations that may be used with older adults and (eg, older adults and people with psychosis) invalid.
describe their strengths and limitations (step 2). Finally, In terms of self-report measures, many of these assess
these assessment tools were summarized and compared hallucinations in a number of different modalities (eg,
with the elements from step 1. Cardiff Anomalous Perceptions Scale, CAPS53–55; Multi-
Modality Unusual Sensory Experiences Questionnaire,
Criteria for Assessment Tools MUSEQ59; Launay-Slade Hallucinations Scale, LSHS47;
A list of the key elements that underpin high-quality as- Extended LSHS48–50), and others are less comprehensive
sessment tools is presented in table 345,46 whereby general (eg, Community Assessment of Psychic Experiences,
issues are presented first, followed by psychometric, struc- CAPE,51,52 and Current CAPE-15).58 Some measures
tural, and practical issues that are specific to the assess- were designed to assess hallucinatory experiences in
ment of hallucinations and to the context of assessing older populations with a particular disorder—such as
older adults in particular. Parkinson’s disease, eg, Psychosis and Hallucination
Questionnaire56,57—whilst others were not specifically
created for assessing hallucinations in a particular dis-
Summary of Existing Assessment Tools for order (CAPS and E-LSHS) but have recently been used in
Hallucinations the clinical studies of older populations, eg, the E-LSHS
Table 4 presents a selection of commonly used assessment has been used in people with Alzheimer’s and older
tools for hallucinations, along with a brief summary of nonclinical populations.74–76 However, as with clinician-
their psychometric properties, and their strengths and administered tools, very little research has directly com-
limitations. Of note, the majority of these measures were pared the use of these self-report measures across age
not developed specifically for older adults—so that their groups, ie, younger vs older adults (but see8,77) and/or di-
design was not necessarily based on the needs of older agnostic groups (ie, clinical vs nonclinical), and it, there-
adults or any specific characteristics of hallucinations in fore, remains largely unknown whether these tools are
older age groups. sample invariant. This is important to consider, because
In table 4, it can be seen that, compared with self-re- if older adults are shown to be using existing tools dif-
port measures, there are relatively few clinician- ferently to younger adults, then changes may need to be
administered tools regularly used with older adults. One made to these tools to accommodate for this; in turn, this
of these (Assessment of Phantosmia) is for a very spe- will help to ensure that these experiences can be assessed,
cific type of hallucination (ie, only for olfactory hallucin- and validly compared, across different groups.
ations), although it has been used in older populations67 Overall, clinician-administered interviews are often
(cf. 68). Another tool, the Auditory Hallucinations Rating already in a suitable and convenient format for older
Scale62,63 is quite brief and assesses just auditory hallu- adults—difficulty reading due to visual loss/impairment,
cinations, but is not widely used (for transcranial mag- items can be repeated for those with hearing loss—though
netic stimulation studies only). The North East Visual clinicians sometimes lack confidence in talking about hal-
Hallucinations Inventory64–66 has good psychometric lucinations, so formal training is required to learn how to
properties and was developed with older populations in approach this topic and to administer items in a standard-
mind but assesses only visual hallucinations. The final ized way. For example, the QPE,69 which was developed
two interview tools—the Psychotic Symptom Rating with input from patient associations in several countries,
Scales (PSYRATS)60 and the Questionnaire for Psychotic provides 50 fully structured questions about hallucin-
Experiences (QPE)69—are quite similar, in that both are ations and is scripted to be low in stigma. However, inter-
detailed in the number of dimensions they assess, al- views can be time-consuming, which may be a problem
though the QPE offers a more complete assessment of for adults with cognitive or motivational difficulties. To
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 Hallucinations and Ageing

Table 2. Recommendations for Training and Practice

Training and Practice Points Examples

➢ Training should sensitize future professionals to the complex Training should aim to:
nature of hallucinations in psychotic and nonpsychotic disorders 1) Provide knowledge about the multifactorial nature of
and raise awareness that hallucinations can, and do, occur in the hallucinations—individual features of the experience are complex

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absence of a diagnosis of mental illness or a need for care. (they can vary in content, emotional valence, frequency, duration,
reality, location, distress, control, etc).
2) Increase understanding that hallucinations have multiple causal
risk factors. Though not an exhaustive list, this includes: physical
(eg, sensory loss/impairment, intoxication, drug abuse/withdrawal,
inflammation), psychological (eg, trauma, bereavement, impaired
cognition, disrupted sleep), and social (eg, loneliness and social
isolation, discrimination) factors.
3) Challenge myths and stereotypes, eg, that hallucinations occur
only in people with psychotic disorders, indicate a propensity to
violence, or are untreatable. Know the facts: hallucinations occur
not only in people with different diagnoses but also in the healthy
population and often respond to treatment.
4) Challenge beliefs about the need for care—hallucinations are
sometimes viewed as helpful and positive, are not always
associated with distress or disruption to daily life, and may not
need an intervention.
➢ Affirming, non-judgmental attitudes and behavior may The following approaches may be helpful:
encourage self-reporting and alleviate distress arising from 1) Avoid trivializing or invalidating the patients’ experience and how
hallucinations in older adults it makes them feel.
2) Ask the patient what their hallucinatory experience is like:
everyone’s experience is different. What (if anything) bothers them
most? Communicate your understanding of what they have said
back to them, to check you have understood them correctly.
3) Be patient, listen carefully, imagine being the person experiencing
hallucinations—put yourself in their shoes.
4) Ask the patient if there are things that do or do not help them
cope with their hallucinations.
➢ When enquiring about the experience of hallucinations Non-stigmatizing ways of asking about hallucinations include:
with older adults and their families/carers use non- “People sometimes hear another person speak, while there is no one
stigmatizing language and provide accurate information there. Also, music or other sounds can be heard, while it is unclear
about the help that is available. where this comes from. In the past 7 days, have you ever heard such
voices, music, or other sounds?”
“Over the past 7 days, have you seen things or images when there was
no clear explanation for them? Or when no one else could see them?
For example, people, animals, shadows, specific patterns, or objects?”
“People sometimes smell the scent of smoke, when there is no fire.
Another example is someone who smells flowers, while there are no
flowers around. Have you ever had this experience in the past 7 days?”
“People sometimes say they experience hearing and seeing things that
others cannot see or hear both at the same time. Or they feel some-
thing/someone touching them they can also see, while others do not.
If you feel comfortable, could you tell something about your
experiences on this?”

conclude, there is a clear need for an increased interest in strive to further adapt, refine, and validate these tools to
hallucinations in older adults, both in terms of research reduce the gap in evidence-based assessment tools avail-
in general and in terms of clinical practice (eg, the devel- able for older adults.
opment and validation of optimal hallucination assess-
ment tools for older adults and the existence of formal Management and Treatment Approaches
clinical training related to hallucinations in older adults).
We encourage those working in a clinical setting to use the Current guidelines and treatment recommendations are
information presented here to choose the optimal halluci- largely based on expert consensus. The focus is typically
nation assessment tools for their working context. These on the overall management of a specific clinical condi-
assessment issues are as important in a clinical setting as tion, with hallucinations one of the symptoms covered,
they are in research. Also, we recommend that clinicians eg, NICE Guidelines for Parkinson’s disease.78 To date,

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J. C. Badcock et al

Table 3. Quality Criteria for Assessment Tools

General: Applies to All Measurement Tools

Possesses good psychometric propertiesa Content validity, internal consistency, construct validity, criterion
validity, test-retest reliability, responsiveness (ie, ability to detect clini-
cally important changes over time), floor and ceiling effects,

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cross-cultural validity, and interpretability (ie, the degree to which one
can assign qualitative meaning to quantitative scores).
Clear and relevant instructions State time period(s), ask participants to answer all the items, tell
participants to exclude certain experiences or contexts (eg, “please
do not include experiences where alcohol, cannabis, ecstasy, or other
similar substances has been taken”), explain the response scale (eg,
for 5-point response scales, inform participants to use the entire scale
and not just the extreme points), and include “unsure/do not know”
response possibility.
Items should be clear and understandable eg, use a clear typeface and legible font size.
Specific: Applies to Measurement Tools for Hallucinations
and in Older Populations
Evidence that it is appropriate and feasible for use with older eg, adequate tool when used specifically with older adults, including
adults those with sensory and cognitive limitations, or physical ill-health.
Psychometric properties are robust when used with older eg, factor invariance between older and younger adults reported, items
populations cover all possible types/modalities of hallucinations (content validity),
test-retest reliability reported (to help clinicians calculating reliable
change indices), and evidence of sensitivity to change the following
treatment.
Captures hallucination-related experiences eg, illusions, misperceptions, intrusive thoughts, flashbacks,
daydreaming, etc. and able to distinguish these from hallucinations.
Assessment beyond presence/absence of hallucinations eg, frequency, variation, location, associated other factors (eg, lighting,
presence of other people, etc.), consistent or variable (is there temporal
consistency?), and impact of the experiences on the person (practical,
emotional, etc.)
Inclusion of additional dimensions associated with the experience eg, whether or not the experience is associated with a certain degree of
distress, conviction, preoccupation, etc.
Inclusion of (a) precise timeframe(s) Specific timeframes (eg, “Have you had this experience in the past
year?”) and/or lifetime timeframes (eg, “Have you ever had this
experience?”). Further, time periods assessed must be able to capture
the new or recent onset of hallucinations vs hallucinations experienced
throughout life.
Question addressing whether or not the individual has talked eg, “Have you discussed these experiences with your partner, carer, or
about the experience(s) with others doctor?”
Different versions of the measure available Versions for: self, informant, clinician.
Question about the interpretability of the items Whether or not the items were clear to the participant (and if not,
which one(s) were unclear/difficult).
Inclusion of a brief screener To identify people for whom a more detailed assessment may be
warranted.
Introductory text states that the experiences have been shown to However, this needs to be done carefully, so that these experiences are
be quite common not further stigmatized.
Assessment beyond hallucinations eg, hearing, vision, health, cognition, medication (and any other
variables that may be considered causally related to the hallucinatory
experience in question), to help distinguish between age-related
sensory change and perceptual anomalies.

Based on Mokkink et al45 and Terwee et al.46

a

few guidelines have focused on hallucinations specif- experiencing hallucinations may not, in itself, require a
ically (eg, 79) and the forthcoming SHAPED (Study of specific treatment beyond general measures (eg, educa-
Hallucinations in Parkinson’s disease, Eye disease, and tion, reassurance, physical, and medication review). For
Dementia) consensus guidelines will be the first to focus example, the SHAPED guidelines suggest including a
on visual hallucinations in older adults. review of cognitive and ophthalmological health, given
All guidelines for hallucinations take the view that that these may be masked by other conditions: ie, cog-
different treatments for hallucinations are required nitive impairment may be missed in a patient with eye
at different disease or hallucination stages and that disease with their decline in functional ability attributed

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 Hallucinations and Ageing

Table 4. Selected Examples of Assessment Tools for Hallucinations

Psychometric Properties in Older

Measure Brief Description Adults Strengths/Limitations

Self-report questionnaires
Launay-Slade Designed to assess hallucination The E-LSHS has good validity E-LSHS assesses a broad

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Hallucinations predisposition in the general community. and internal reliability (Cronbach’s range of hallucinations in
Scale (LSHS).47 Original α = .87).49,50 different modalities, in-
version has 12 items (Launay and Slade47); Factor analyses of the E-LSHS indicate cluding auditory, visual
an extended version has 16 items.48 a 4-factor solution measuring; (a) and olfactory, and items
Items rated on a 5-point Likert scale: auditory and visual HLEs, (b) on hypnagogic and hypno-
“0 = certainly does not apply to me,” multisensory HLEs, (c) intrusive pompic hallucinations and
“1 = possibly does not apply to me,” thoughts, and (d) vivid daydreams. on sensed presence hallu-
“2 = unsure,” “3 = possibly applies Psychometric data in older adults are cinations.
to me,” and currently being examined. For the 3
“4 = certainly applies to me.” LSHS auditory hallucinations items,
Cronbach’s α = .869 in adults 60+ yrs
(data derived from reference 8).
Community 42-item measure—designed to assess lifetime Good validity and reliability, especially Provides comprehensive
Assessment of psychotic-like experiences in the general in younger samples. However, positive information about lifetime
Psychic population. and negative subscales may be less psychotic experiences.
Experiences It contains 3 subscales assessing positive, reliable in older adults.52 Available in 8 languages
(CAPE).51 negative psychotic (from: http://cape42.home-
symptoms, and depressive stead.com/index.html)
symptoms and also includes ratings Quite long.
of distress.
Cardiff Anom- 32-item measure—designed to Good validity in nonclinical (18–54 yrs) Uses neutral, everyday lan-
alous assess anomalous perceptual and clinical (psychotic disorder) groups guage.
Perceptions Scale experiences in the general (25–64 yrs). Good internal reliability Designed to assess anom-
(CAPS).53,54 community and clinical groups. (Cronbach α = .87) and test-retest re- alous perceptual experi-
Items scored YES or NO. liability over 6 months (CAPS Total ences, rather than general
If YES, items then rated for distress, r = .77). Total scores uncorrelated with aspects of psychosis-like
intrusiveness, and frequency on a 5-point age.53 experiences.
Likert scale. Psychometric properties in older adults Validated in Spanish.55
(50 yrs and above) currently being Freely available: https://osf.
examined. io/fm34z/
Quite long.
Psychosis and 20-item measure—designed to Good validity, good test-retest Brief, typically < 10 mins.
Hallucinations assess hallucinations and other (intra-class correlation = 0.9), and Developed in consultation
Questionnaire psychotic symptoms, attention, and sleep internal reliability (Cronbach α = 0.9) with patients, caregivers,
(PsycHQ).56 disturbance in Parkinson’s Disease (PD). in older patients with idiopathic PD.56 and clinicians and uses
Informant ver- Frequency is rated on a 5-point (Note: average age of patients with layman language.
sion available.57 Likert scale: Never, < 1 time per week, positive response on PsycHQ 70.5 ± 8.5 Questionnaire available
Weekly, Most days a week, Daily. yrs). from the authors upon re-
Distress is rated on a 4‐point Likert scale: Scores on Section I (core hallucinatory quest.
None, Mild, Moderate, and Severe. and psychotic symptoms) uncorrelated Probes a broad spectrum
with age, disease duration, motor of visual and nonvisual
severity, or daily Levodopa equivalent hallucinatory phenomena.
dose. Can help pick up PD
hallucinations that may
otherwise go missed by
clinicians. Utility for as-
sessing hallucinations in
other disorders unclear.
Current 15-item version of the CAPE-42 measures Good validity and internal reliability in Provides information
Community positive “psychotic-like” experiences that younger adults (Cronbach’s α = .79)58 about recent hallucinatory
Assessment of have occurred in the last 3 months. Psychometric properties in older adults and psychotic-like experi-
Psychic Contains 3 subscales measuring not ences.
Experiences-15 persecutory ideation, bizarre evaluated. Shortened version of the
(Current experiences, and perceptual original 42-item CAPE
CAPE-15).58 abnormalities, including ratings of distress. questionnaire.
Questionnaire freely avail-
able.58

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J. C. Badcock et al

Table 4. Continued

Psychometric Properties in Older

Measure Brief Description Adults Strengths/Limitations
Multi-Modality 43-items assess unusual sensory Acceptable test-retest reliability Provides information
Unusual Sen- experiences in 6 modalities: (r = .56– 0.77) and good internal about sensory experiences
sory Experiences auditory, visual, olfactory, reliability (Cronbach α = .77–88), and in a number of modalities.

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Questionnaire gustatory, bodily sensations, and sensed good construct and discriminant va- Items designed to assess
(MUSEQ).59 presence. lidity in nonclinical (mean = 27.75 and unusual sensory experi-
Items rated on a 5-point Likert scale: 0 = range 17–76 yrs) and clinical groups, ences according to a
Never, 1 = Hardly Ever, 2 = Rarely, including schizophrenia continuum structure (ie,
3 = Occasionally, and 4 = Frequently. spectrum disorder and bipolar disorder most frequent to least
(mean = 34.17 and range 18–67 yrs.). frequent phenomena).
Psychometric properties in older adults Open access.59
not Quite long.
evaluated.
Clinician Administered
Psychotic Structured interview for auditory hallucin- Good inter-rater and test-retest Provides a comprehensive,
Symptom ations (and delusions) in patients with reliability, and good validity. multidimensional
Rating Scales psychotic disorders. Factor analysis shows a 4-factor assessment of auditory
(PSYRATS).60 Symptoms in the last week are rated: solution measuring Distress, Frequency, hallucinations.
0 = no problem, 1 = minimal or occasional, Attribution, and Loudness.61 German, French,
2 = minor to moderate, 3 = major, and Indonesian, Malay,
4 = maximum severity. Portuguese, and Chinese
Auditory hallucinations are also evaluated translations available.
on frequency, duration, location, loudness,
beliefs regarding origin of voices, negativity,
distress, disruption, and controllability.
Auditory Hal- Brief (7-items), structured clinical interview Adequate inter-rater and test-retest Provides a shorter
lucinations that measures the frequency, reality, reliability and moderate internal alternative to the
Rating Scale loudness, number of voices, length, consistency (Cronbach’s α = .60).62 PSYRATS.
(AHRS).62,63 attentional salience, and distress of auditory Psychometric properties in older adults Not widely used.
hallucinations. not explored.
North East Semi-structured interview designed to assess Good validity and good inter-rater and Includes brief screening
Visual Hallucin- hallucinations in older adults with eye internal reliability (Cronbach α = .71).65 questions.
ations Inventory disease and cognitive impairment. Good convergent and divergent validity Examines both simple and
(NEVHI).64 Qualitative items rated on a 3-point Likert in older adults with PD complex visual
scale: 0 = never, 1 = sometimes, and (mean age 68.9 ± 7.6 yrs).66 hallucinations.
2 = always. Explores social, emotional,
and behavioral impact of
hallucinations.
Assessment of Single-item measure (“Have you in the last Psychometric properties not formally Brief administration time.
Phantosmia.67 year experienced the so-called phantom assessed. However, phantosmia was not Captures qualitative
smells?”) scored 0 = “Never” to correlated with olfactory dysfunction, features of phantom
4 = “Always.” When present, fixed follow-up supporting the discriminant validity of smells.
questions enquire about the type, intensity, objective and subjective olfactory Some people may not fully
duration, frequency, recency, and chronology measures. understand the meaning
of the experience. Prevalence of phantosmia reported to of Phantosmia. Responses
be uncorrelated with age in healthy may be subject to bias.
individuals (60–90 yrs).
Assessment of Standardized assessment with a single, Psychometric properties not reported. Assessment limited to
Phantosmia.68 negatively valenced item “Do you sometimes For adults 40 yrs and above, an olfactory modality.
smell an unpleasant, bad, or burning odor age-related decline in unpleasant, bad, Positive or neutral
when nothing is there?” or burning phantosmia observed for phantom smells are not
Responses coded: Yes/No. women but not men. assessed.
No information on
intensity, duration, or
periodicity.

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 Hallucinations and Ageing

Table 4. Continued

Psychometric Properties in Older

Measure Brief Description Adults Strengths/Limitations
Questionnaire for 50-item QPE designed to assess the presence, Good validity and good test-retest Designed for use across a
Psychotic Experi- severity, and phenomenology of reliability, inter-rater reliability, and range of disorders.
ences (QPE).69 hallucinations (and delusions) across internal consistency in patients with Available from: www.

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diagnostic groups. schizophrenia, schizoaffective disorder, qpeinterview.com/en
bipolar disorder, and major depressive Quite long: 20-40mins
disorder and nonclinical participants administration time (but
(mean age: 40.3, 43.4, 32.1, 30.2, and high completion rate, see
28.6 yrs, respectively). reference 69).
Psychometric properties in older adults/ Requires training
other diagnoses currently under No specific comparisons
examination. of QPE between older and
younger adults.

to visual loss. Early provision of information about the the treatment of choice. In one or more sessions, the pa-
risk of hallucinations is emphasized as a way of reducing tient and his/her loved one can be provided with informa-
stigma and for healthcare professionals to routinely ask tion about how perception is accomplished in the brain,
about hallucinations—to shift the onus of reporting hal- how this process can go awry, and which factors can pre-
lucinations away from the patient. The point at which cipitate hallucinations. A good start for psychoeducation
specific pharmacological or non-pharmacological inter- is to ask the patient what he/she already knows and which
ventions for hallucinations are required is not clearly de- explanation he/she currently uses for this experience.
fined in guidelines but based on clinical judgment. From there, unhelpful explanations can be corrected and
new knowledge can be added to improve disease insight.
For Purpose 2: Psychological Therapy. If the answer is close
Differential Diagnosis to the description under point 2, then psychological therapy
Before commencing treatment, it must be clear that hal- that helps the person to develop effective (and avoid inef-
lucinations are causing distress, ie, that there is a need for fective) strategies and skills for coping with hallucinations,
treatment. If this is the case, the second point of attention and any distress associated with these experiences, is recom-
is whether it is indeed hallucinations. Especially in older mended. Cognitive behavioral therapies help clients think
adults with cognitive dysfunction, it can be difficult to dis- and feel differently about hallucinations. Improving coping
entangle hallucinations from obsessions, misperceptions/ skills can also help to reduce distress, which may contribute
misunderstandings (ie, illusions), or involuntary mental to the onset or maintenance of hallucinations.81 In the case
imagery, such as the so-called "earworms” (ie, songs in of bereavement hallucinations, it is important to take a
the mind that continually repeat).80 relational psychotherapeutic perspective on the experience,
as the distress may signify relationship difficulties with the
deceased, eg unfinished business and intrusive presence.82,83
Purpose of Treatment Several psychotherapies initially developed for treating
For some disorders, such as intoxication, psychotic de- people with a primary psychotic disorder and auditory hal-
pression, and schizophrenia, hallucinations may respond lucinations (cognitive behavioral therapy, COMET, accept-
well to treatment of the underlying disorder. However, ance, and commitment) are also applied to older persons,84,85
in other disorders, such as dementia, vision or hearing though less is known about the application of cognitive be-
loss, or Parkinson’s disease, this is not the case. In such havioral therapy for distressing visual hallucinations.86 In
instances, additional treatment aimed specifically at hal- some cases, adjustments need to be made when the cognitive
lucinations may be indicated. For the treatment of hal- resources of patients are limited. The essence of such ther-
lucinations, the most important question is what the aim apies is that the patient learns that hallucinations are not a
of treatment should be. There are a number of answers real-life threat, may have personal significance or meaning,
frequently given to this question: or can safely be ignored. If (auditory) hallucinations have
neutral content, then psychotherapy developed for tinnitus
1. I want to understand why I experience these
may be a better fit, as it focuses on the reduction of worry,
hallucinations.
and shifting attention away from the unwanted perceptions.87
2. I want to be competent to handle these hallucinations.
3. I want to get rid of these hallucinations.
For Purpose 3: The Following Steps Can Be Used. Step
For Purpose 1: Psychoeducation. If the response to this 1: Check Medication Checking medication records is
question is in line with answer 1, then psychoeducation is important since several types of medication can induce
Page 9 of 14
J. C. Badcock et al

hallucinations, especially those with anticholinergic for potential QT elongation should be performed before
activity and those that increase monoaminergic func- and after the start of risperidone, aripiprazole, and typ-
tion. People with cognitive dysfunction are at partic- ical antipsychotics.92As antipsychotic use has been asso-
ular risk for such side effects. The most commonly used ciated with significant mortality and morbidity risks for
hallucination-triggering medication are corticosteroids, older patients, especially those with dementia, such med-
levetiracetam (an anti-epileptic drug), anti-malaria med- ication should be avoided if possible and tapered off if
ication, dopaminergic agonists (pramipexole, rotigotine, not effective or when hallucinations have been in stable

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ropinirole, etc.), losartan (an antihypertensive drug), and remission when it is used.91,93
opioids such as tramadol. If there is a correlation in time Hallucinations, especially in the visual domain, in older
between the onset of hallucinations and start of medica- adults can also arise from the loss of cholinergic inner-
tion use, it may be worthwhile to taper off that medicine vation, especially in people with neurodegenerative dis-
or replace it by another one and reevaluate hallucination orders, such as Alzheimer’s, Huntington’s, or Parkinson’s
severity. disease. As acetylcholine is an important neurotrans-
mitter in sustained attention, patients with loss of cho-
Step 2: Risk Factor Management Risk factors for hal- linergic innervation often show drowsiness, inattention,
lucinations include physical health, environmental, psy- and forgetfulness (“what was the reason I went to the
chological, and social factors. Any obvious triggers to kitchen?”). Cholinesterase inhibitors such as donepezil,
the hallucinations should be identified. Comorbid phys- rivastigmine, and galantamine can be effective in treating
ical health factors increase the risk of hallucinations, this type of hallucination.94,95 If using rivastigmine,
including visual and hearing impairment and physical patches may be better tolerated than pills as they provide
illnesses (eg, some metabolic and endocrine disorders, and fewer gastrointestinal side effects.96,97 Starting dose is usu-
psychiatric disorders such as depression and psychotic ally 4.6 mg/24 hours, which is increased to 9 mg/ 24 hours
disorders). Optimize sensory modes by using glasses, per- after 3–5 weeks if generally tolerated, although side ef-
haps cataract operation is an option, use hearing aids. fects are also common.98
Good sleep hygiene is key, with darkness in nighttime and
bright lights (preferably sunlight) at day. In terms of envi- Step 4: Physical Therapy In older individuals, pharma-
ronment, it is key to provide well-lit rooms, without dark cotherapy often induces side effects. Further, antipsy-
corners. Reduce background noise as much as possible, chotic medication use in the elderly has been associated
especially during conversations. At the social level, good with increased mortality.91,93 Hence, an alternative treat-
company is an excellent prevention for hallucinations and ment may be to use electrical or magnetic therapies.
may reduce their frequency and intensity. Electroconvulsive therapy (ECT) is not only the best-
known option but also the most intensive one. ECT may
Step 3: Pharmacotherapy If the patient wants to re- be an excellent option for older adults with psychotic de-
duce hallucinations and previous strategies were not suc- pression as it is rapid and highly effective for both the
cessful, pharmacotherapy can be an effective means to do depressive and the psychotic symptoms. Cognitive side
so, although side effects may be severe, especially in older effects can occur but are generally not lasting and may be
people. It is important to discuss the unstable course of ameliorated by the use of cholinesterase inhibitors during
hallucinations and the possibility that they will disappear the ECT course.99 For other types of hallucinations in
spontaneously. Considering that hallucinations can arise older adults, ECT is seldom used. Transcranial magnetic
from aberrations in many neurotransmitters systems, in- stimulation and transcranial direct (or alternating) cur-
cluding the dopaminergic, serotonergic, glutamatergic, rent stimulation have been mostly applied for auditory
and cholinergic system, then specific medication may be verbal hallucinations,100,101 but could also be an option for
effective only in specific subtypes. The phenomenology tactile hallucinations.102,103
of the hallucinations may provide some clues to the di-
rection of which receptor system may be involved.88 For
Summary and Directions for Future Research
example, dopamine couples salience to experiences and
increased dopamine production can lead to highly sa- Hallucinations are common in older adults. The character
lient, often frightening hallucinations, as seen in people of these experiences is varied and for many, though not
with psychotic depression, schizophrenia, delirium, and all, they can cause significant distress. Understanding the
post-traumatic stress disorder. Antipsychotic medication diverse origins, nature, and reactions to hallucinations is
can be effective for this specific type of hallucinations.89–91 vital in helping clinicians to provide the best level of care
As dopamine receptors decrease with age, much lower (see Resources). There is currently no consensus on the
dosages are used for older adults; hence, the adage “start most suitable tool(s) for assessing hallucinations in older
low, go slow” to titrate until the lowest effective dose is individuals, with or without a co-occurring clinical dis-
achieved. Sedative antipsychotics need to be given at order. A range of valid and reliable measures is available
nightime to reduce the risk of falls. Electrocardiogram for the screening and assessment of hallucinations, though
Page 10 of 14
 Hallucinations and Ageing

these were largely not designed specifically for older age Programme Grants for Applied Research Grant
groups. Variation in the scope and content of these meas- (RP‐PG‐0610‐10100-SHAPED).
ures means that: (1) the phenomenological features, emo-
tional reactions, and impact on the life of hallucinations Acknowledgments
in older patients may be incompletely captured and (2)
differences in the experience of hallucinations across age The views expressed are those of the authors and not
groups or diagnostic categories may be missed. Clinicians necessarily those of the NIHR or the Department of

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also need to maintain awareness of potential barriers to Health and Social Care. Sommer, Collerton, and Larøi
disclosure of hallucinations and the value of gaining in- are co-developers of scales included in table 4. There are
formation from multiple sources (self, informant, and no other conflicts of interest in relation to the subject of
clinician) when discussing these experiences with older this study.
clients. Similarly, although treatment and management
approaches are slowly being tailored to the needs, views, References
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