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Case presentation
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Geriatrics
45
PSYCHIATRIC CONSULTANT
67% of patients experienced the
hallucinations with their eyes opened.
Most patients experienced the hallucinations during the evening or at
night, under conditions of poor lighting, and when they were inactive or
alone. Keeping their eyes closed, looking or walking away from the visions,
or turning on lights helped stop the
hallucinations. Patient emotional reactions varied: 32% became anxious
or distressed and 13% were amused.
Most patients did not report their
hallucinations to others out of fear
that they would be considered mentally ill.
Risk factors
For some patients, the visual hallucinations might precede or indicate the
presence of dementia. Pliskin et al
found that 14 CBS patients referred to
a psychiatry clinic exhibited cognitive
deficits suggestive of early dementia.2
By contrast, Holroyd and Rabins conducted a 3-year follow-up study of 100
AMD patients, 13% of whom had visual hallucinations, and found that no
patients experienced cognitive decline
during the study period.5
The strongest risk factors for CBS
include bilateral visual system impairment, declining visual acuity, cognitive deficits, stroke, and Alzheimers
disease. The etiology of CBS is unknown, although one theory suggests
that deafferentation of the visual system may alter receptive fields in the visual cortex and lead to spontaneous
neuronal discharge and hallucinations.6
Treatment
Geriatrics
Dosage range
Comments/precautions
Olanzapine
(Zyprexa)
2.5 to 10 mg/d
Quetiapine fumarate
(Seroquel)
25 to 100 mg/d
Same as olanzapine
Risperidone
(Risperdal)
Same as olanzapine
Ziprasidone
(Geodon)
20 to 40 mg/d
Case resolution
References
1. 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):90-8.
2. Pliskin NH, Kiolbasa TA, Towle VL, et al.
Charles Bonnet syndrome: An early
marker for dementia? J Am Geriatr Soc
1996; 44(9):1055-61.
3. Teunisse RJ, Cruysberg JR, Hoefnagels
WH, Verbeek AL, Zitman FG. Visual
hallucinations in psychologically normal
people: Charles Bonnets syndrome.
Lancet 1996; 347:794-7.
4. Scott IU, Schein OD, Feuer WJ, Folstein
MF. Visual hallucinations in patients
with retinal disease. Am J Ophthalmol
2001; 131(5):590-8.
5. Holroyd S, Rabins PV. A three-year
follow-up study of visual hallucinations
in patients with macular degeneration. J
Nerv Ment Dis 1996; 184(3):188-9.
6. Rabins PV. The genesis of phantom
(deenervation) hallucinations: A
hypothesis. Int J Ger Psych 1994;
9:775-7.
7. Ranen NG, Pasternak RE, Rovner BW.
Cisapride in the treatment of visual
hallucinations caused by vision loss:
The Charles Bonnet syndrome. Am J
Geriatr Psychiatry 1999; 7(3):264-6.