Case report

Auditory musical hallucinations as debut of late-onset acute psychosis

Autors:

Abstract
Introduction: the appearance of psychotic symptoms in elder people without psychiatric
history –in form of complex auditory hallucinations– can be indicative of a cognitive
impairment onset.
Methods: Female, 73 years of age, with normal prior behavior and without prior
psychiatric history, seeks medical help accompanied by her husband after experiencing
audio hallucinations. These have been appearing for three months and are of musical and
verbal kind (megafonia), implying high emotional and behavioral impact.
Results: In addition to the pathological neuropsychological evaluation, we observed
vascular chronic injuries in the neuroimaging performed. Alteration in the
visuoconstructive capacity, executive functions, planning and new learning has been
detected.
Conclusions: The presentation of this case, apart from being interesting could prove the
significance of complementary clinical examination and the neuropsychological evaluation.
Keywords: late-onset acute psychosis (LOAP), Auditory hallucinations (AH),
electroencephalogram (EEG), brain magnetic resonance (MRI), Positron Emission
Tomography (PET), Otorhinolaryngology (ORL), MiniMental State Examination (MMSE),
Montreal Cognitive Assessment (MoCA).

and/or musical content. Whenever it

Introduction
The interest of the study of acute
psychotic states with delayed start and its
relationship with cognitive impairment or
dementia is slowly increasing. It appears
to be an agreement that this impairment
determines the appearance of some
neuropsychiatric alterations, which
usually are indicators of the illness
evolution (3). These symptoms in patients
with cognitive impairment cause
discomfort and tension for its caretakers
and medical personnel, especially due to
the behavioral changes and its difficult
treatment. The presentation of LOAP can
be characterized in great part by
delusions, visual hallucinations (30%),
auditory hallucinations (AH) (10%),
paranoid interpretations (errors in
perception) and other Schneider
symptoms (3). An AH is a more complex
perception than a tinnitus, having a verbal
exists self-consciousness of the stimulus
inexistence in the environment, it is
known as hallucinosis.
The AH are common neuropsychiatric
symptoms seen in specific
neurodegenerative disorders, especially
alfasynucleinopathies and Alzheimer
Disease (12% of cases). Dementia with
Lewy Bodies is more often associated
with AH and, in fact, they are part of the
diagnostic criteria. They appear
predominantly in females and comorbid
to auditory deficiency, depression,
delirious ideas or visual hallucinations
(2).
In other cases, focal lesions in the central
auditory system explain the AH, being
vascular etiology the most frequent (1).
Frequently in AH intervenes a causing
and a triggering factor. For example, the
hallucinations triggered by medications
are more probable in people with hearing
loss; in some patients with cerebral
injuries, the hallucinations occur when
there is a paroxistic bioelectric activity;
even there has been association with
thalamus-striatum calcification leading to
hypoparathyroidism, being the AH
reversible once the alterations in
phosphocalcic metabolism are corrected
(1). The reduction of cholinergic neurons
that occurs with aging can be also
considered a leading factor and, combined
with visual or audio deficiency, can cause
hallucinations.
The cases of cognitive impairment
increase with age, the average age being
77 years. This is in agreement with what
is observed with the subgroup with audio
deficit of 66.4 years of age.(1)
According to literature, the audio verbal
hallucinations are associated with an
increased activity in the primary and
secondary audio cortex, areas of Brocca
and Wernicke, the amigdalohypocampal
complex and cingulate anterior cortex.
Case studies on temporary epilepsy and
deep brain stimulation using MRI,
associate the auditory hallucinations with
the temporary left cortex (4). Other series
find relationship with vascular lesions in
the mesencephalon, pons, left temporal
lobe and left claustrum (1).
Fig1- Robles Bayóna, M.G. Tirapu de Sagrariob y F. Gude
Sampedroc -Alucinaciones auditivas en neurología cognitiva-
9marzo 2016
Materials and methods:
Revision of the literature and case report.
Results:
The case is about a 73-year-old female
patient, Caucasian, of Spanish origin. She
has medical history of hypothyroidism
and dyslipidemia under treatment,
without any own nor familiar psychiatric
history. No history of drug abuse. At this
time, under treatment with natural
products for weight loss and against hair
loss. Retired Secretary, independent for
the basic daily activities.
She seeks medical help accompanied by
her husband after experiencing AH of
musical and verbal type (megafonia)
since 3 months, with high emotional and
behavioral impact.
On admission, she appears treatable,
cooperative, oriented in person, place and
time. With poor syntonic contact,
childish, without alterations in the
attention or the speaking, with mnesic
deficits and tendency for fabulation.
Hyperthymia. Circumstantial speech and
delirious ideas of erotomaniac, mystical
and megalomaniac type: “my husband’s
ex boss wants to be priest to marry me
and he can only do it because I am a
Saint.” She has low insight.
Physical and neurological examination
without alterations.
RX of torax normal. EEG without
epileptic activity.
Drugs in urine sample: negative. The
blood analysis shows hypothyroidism
(TSH: 5.447 A/m UIL; T4 1.24 mg/dl), so
it is increased the dose of Levotiroxine
from 75 to 100 mcg/day. Rest of
parameters under normal range.
Within the complimentary evaluations:
Otorhino: we find cerumen clogging the
audio channel. The specialists consider
there is no need for an audiometry.
CT scan: dilated ventricles and mild
fronto-temporo-parietal atrophy.
MRI shows multiple difuse hiperintense
lesions in white matter, mainly in
frontobasal and parietal cortex, which
could be associated with microvascular
chronic alterations. Scars in the cerebellar
hemispheres.
PET: slight frontal bilateral
hypometabolism, of right predominancy.
Neurpsychological evaluation: MMSE:
28/30. MOCA: 23/30. CI: 105-107
(normal). Alterations in
visuoconstructive, codification, executive
functions and short-term memory.
Difficulty in learning, lack of self-
planning and structuring the execution.
FIG2 B CAT
FIG3 RMC
Figura 2 y 3 : dilation of the lateral ventricles,
frontoparietotemporal atrophy, mild
microangiopathies and scars at the level of
cerebellar .hemispheres.CAT atrofia
frontotemporal y ventrículos dilatados.
RM cerebral Microangiopatias leves lesiones
hipertintensas difusas frontobasales y
parietales a nivel de sustancia blanca
During her stay in the hospital she has
good interaction with her husband and
maintains an hyperfamiliar behavior with
the medical team. They appear delirious
ideas of perjudice (“Ignacio – the ex boss
– wants to marry me to get my
properties”) and paranoid ideas about the
neighbors talking about her, as well as
getting convinced of being a victim of
cyberbullying according to a newspaper
article. No current insight.
We started oral risperidone 3 mg per day,
increasing progressively the dose up to 6
mg (3-0-3), without side effects and with
partial remission of the AH that decreased
to intensity 3/10. Certain paranoid
delirium persists regarding to the
cyberbullying but there is improvement of
the insight, which allows her to function
under supervision. After one month of
stay and partial decrease of the
symptoms, she is discharged.
Discussion:
When facing a late-onset acute psychosis,
we have to take into account the clinical
symptoms and the time of evolution,
searching for potential causing factors
and triggering factors. We initially have
to discard the most probable causes: (1)
otorhinolaryngological (she had no
hipoacusia), (2) drug abuse (we didn’t
find any evidence of possible trigger in
her natural medication), (3) metabolic
causes (such as hypo/hyperthyroidism,
the correction of hormone levels didn’t
improve the psychotic symptoms), (4)
temporary epilepsy (normal EEG), (5)
infections, (6) focal lesions in areas
intervening in the processing of auditory
information, (7) neurodegenerative
diseases and many other causes. In her
case, the cerebral MRI showed dilation of
the lateral ventricles,
frontoparietotemporal atrophy and focal
lesions in the CNS compatible with mild
microangiopathy.
Despite no alteration in the life common
activities, the neuropsychological test
showed cognitive impairment in frontal
functions, compatible with the PET
results. We want to highlight the known
higher sensitivity of MoCA exam
compared to MMSE (5), especially in
vascular causes, as we see in our patient.
Therefore, the results of the imaging and
neuropsychological evaluation suggest a
probable cognitive impairment of
vascular origin, debuting with HA.

Conclusions:
Despite not having primary psychiatric
history, the LOAP in this patient can have
been induced by multiple vascular
injuries. We point out that the
frontoparietal lesions and cerebellar scars
detected, could have an influence in the
clinic, not only as a cause of vascular
dementia, but also as these areas are
considered modulating beams in the
auditory afferent pathway, concretely on
the ascendant reticular activating system
that connects the cochlear nucleus with
the auditory thalamus. The hallucinatory
symptoms of musical type are particular
in this patient, being a sign of alert that
leads us to the search of other causes, and
to vascular cognitive impairment.

Bibliografía:
1- Robles Bayóna, M.G. Tirapu de Sagrariob y F. Gude
Sampedroc -Alucinaciones auditivas en neurología cognitiva-9
marzo 2016
2-Naoko Tsunoda, Mamoru Hashimoto, Tomohisa Ishikawa, et al.
Clinical Features of Auditory Hallucinations in Patients With
Dementia With Lewy Bodies: A Soundtrack of Visual
Hallucinations. J Clin Psychiatry 2018; digital object identifier
(doi): 10.4088/JCP.17m11623.
3-M. Pilar Elías-Villanueva, Maeva Fernández-Guardiola,
Arancha Ortiz-Martín, Sandra Gallego-Villalta Psicosis de inicio
tardío -Unidad de Agudos de Psiquiatría. Hospital Royo Villanova
Zaragoza, España.,2011
4-M. Fonta, E. Parelladaa, E. Fernández-Egeaa, M. Bernardoa y F.
Lomeñab a Neuroimagen funcional de las alucinaciones auditivas
en la esquizofrenia Instituto Clínico de Psiquiatría y Psicología.
Hospital Clínico y Universitario de Barcelona. bServicio de
Medicina Nuclear. Instituto de Investigaciones Biomédicas August
Pi i Sunyer
https://www.researchgate.net/publication/228711958_Neuroimage
n_funcional_de_las_alucinaciones_auditivas_en_la_esquizofrenia
[accessed Oct 14 2018].

5. (añadir de sesión demencias vasculares)