PT  - JOURNAL ARTICLE
AU  - O'Brien, John
AU  - Taylor, John Paul
AU  - Ballard, Clive
AU  - Barker, Roger A
AU  - Bradley, Clare
AU  - Burns, Alistair
AU  - Collerton, Daniel
AU  - Dave, Sonali
AU  - Dudley, Rob
AU  - Francis, Paul
AU  - Gibbons, Andrea
AU  - Harris, Kate
AU  - Lawrence, Vanessa
AU  - Leroi, Iracema
AU  - McKeith, Ian
AU  - Michaelides, Michel
AU  - Naik, Chaitali
AU  - O'Callaghan, Claire
AU  - Olsen, Kirsty
AU  - Onofrj, Marco
AU  - Pinto, Rebecca
AU  - Russell, Gregor
AU  - Swann, Peter
AU  - Thomas, Alan
AU  - Urwyler, Prabitha
AU  - Weil, Rimona Sharon
AU  - ffytche, Dominic
TI  - Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management
AID  - 10.1136/jnnp-2019-322702
DP  - 2020 May 01
TA  - Journal of Neurology, Neurosurgery & Psychiatry
PG  - 512--519
VI  - 91
IP  - 5
4099  - http://jnnp.bmj.com/content/91/5/512.short
4100  - http://jnnp.bmj.com/content/91/5/512.full
SO  - J Neurol Neurosurg Psychiatry2020 May 01; 91
AB  - Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson’s disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson’s disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.