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Objective: Studies suggest a link between visual acuity and visual hallucinations in dementia, but links with specific eye pathologies have not been evaluated. Method: Fifty patients (20 with visual hallucinations, 30 without) with probable Alzheimers disease had an
evaluation of psychotic symptoms. Visual acuity was measured before and after refractions, and ophthalmological examinations included standardized assessments for cataracts and macular degeneration. Results: Impaired visual acuity and the severity of cognitive impairments were significantly associated with visual hallucinations. No patients with
normal acuity (6/5 or 6/6 on the Snellen chart) experienced these symptoms. Impaired acuity improved with refraction in 60% (N=12) of the patients with visual hallucinations. Of specific eye pathologies, only cataracts were significantly associated with visual hallucinations.
Descriptive follow-up information suggests that an opticians assessment for glasses improves outcome. Conclusions: Glasses and cataract surgery need evaluation as prophylactic or adjunctive treatments for visual hallucinations in patients with probable Alzheimers
disease.
(Am J Psychiatry 1999; 156:19831985)
any (more than 20%) of the patients with Alzheimers disease experience visual hallucinations.
They are distressing (1), precipitate admission to residential care (1), and are associated with more rapid
cognitive decline (2). Reports (1, 3) suggest a link between visual hallucinations and visual impairment, although impaired acuity was inferred from clinical interviews in two studies. This report examines the
association among visual hallucinations, acuity, and
specific eye pathologies in 50 patients with probable
Alzheimers disease.
METHOD
Consecutive patients with dementia were included in a case registry. The History and Aetiology Schedule (4) was used for the study;
it records psychiatric and past medical history, medication, and the
results of a standardized physical examination. Psychotic symptoms
were rated with the Columbia University Scale for Psychopathology
in Alzheimers Disease (5), from which operationalized diagnoses of
visual hallucinations, delusions, and delusional misidentification
were made (6). An appendix rated the minutes of visual hallucinations over the week before the assessment. Cognitive assessments
were made with the cognitive section of the Cambridge Examination
for Mental Disorders of the Elderly, section B (7). A diagnosis of
probable Alzheimers disease was made according to the criteria of
the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimers Disease and Related Disorders
Association (8).
Postmortem examinations were obtained from 50 of the 338 case
registry patients. The positive predictive value for probable Alzheimers disease in a clinical setting against a neuropathological diagnosis was 80% (9).
Fifty patients with probable Alzheimers disease were selected for
ophthalmological evaluation (20 with visual hallucinations, 30 without). Patients and caregivers were shown an information sheet that
1983
BRIEF REPORTS
0
0
4
5
3
4
0
4
0
0
20
25
15
20
0
20
4
7
7
5
2
2
1
2
13
23
23
17
7
7
3
7
76.3
64.0
58.3
56.1
59.6
43.7
59.0
43.0
13.3
22.4
12.9
16.8
12.7
11.3
0
33.5
a The
explained the study in full. If they wished to participate, written consent was obtained from the patient and written assent from the next
of kin. Approval was obtained from the relevant ethical committee.
Binocular acuity with existing glasses was measured by the
Snellen chart. All patients were refracted by the study optometrist
and examined by an ophthalmologist (F.M.C.) who was blind to the
subjects hallucination status. Assessments included the visual field
evaluation to confrontation and the slit lamp biomicroscopy before
and after pupil dilation. Cataracts were defined by a simplified Oxford cataract grading system (10). Age-related macular degeneration
was graded by using photographs from the Wisconsin age-related
macular degeneration grading system (11) and scored when visually
significant.
Visual acuity and cognitive impairment were compared among
patients with and without visual hallucinations by using the MannWhitney U test. Cataracts were compared between the two groups
by using chi-square analysis. Statistical analyses were made with the
SPSS computer software.
RESULTS
Sixty-two case registry patients with probable Alzheimers disease were living at the time of the study. All
20 with visual hallucinations and 30 who were randomly selected from the 42 without hallucinations were
enrolled. Mean age at assessment was 81.7 years for
hallucinators and 79.2 years for nonhallucinators. Seventeen of the 20 hallucinators were women, compared
to 17 of the 30 nonhallucinators (2=4.1, df=1, p=
0.04). Hallucinators had significantly worse mean
scores than nonhallucinators on the cognitive section of
the Cambridge Examination for Mental Disorders of
the Elderly (48.6 and 62.7) (Mann-Whitney U, z=2.6,
p=0.009). Visual acuity was also significantly more impaired in hallucinators (Mann-Whitney U, z=3.0, p=
0.003) (table 1). No patients with visual hallucinations
had normal acuity (6/5 or 6/6 on the Snellen chart).
Hallucinators with a visual acuity of 6/12 or worse
had 33.7 minutes of visual hallucinations in the week
before the assessment compared to 3.3 minutes for the
hallucinators without impaired visual function, and
eight of 13 (62%) of the hallucinators with poor visual
acuity (6/12 or worse) who completed the follow-up
1984
BRIEF REPORTS
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Predictive accuracy of clinical diagnostic criteria for dementia
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1985