Visual hallucinations in dementia: A prospective community-based study with autopsy

OBJECTIVE:: Several studies have demonstrated that specific neuropathologic features may be associated with the presence of visual hallucinations in dementia patients, but the clinical usefulness of these studies has been limited because their subjects were selected on the basis of neuropathologic findings rather than clinical presentations. This study seeks to investigate the demographic, clinical, and neuropathologic features of community-based dementia subjects with and without visual hallucations. DESIGN:: A prospective examination of the clinical and neuropathologic correlates of visual hallucinations in community-based dementia subjects. PARTICIPANTS:: One hundred forty-eight subjects with sufficient clinical and neuropathologic data from a community-based incident dementia autopsy case series. RESULTS:: Subjects were classified according to the presence or absence of visual hallucinations and subjects with visual hallucinations (N ≤ 27) were younger at intake and more likely to exhibit agitation, delusions, and apathy than subjects without visual hallucinations (N ≤ 121). Subjects with visual hallucinations were also more likely than subjects without visual hallucinations to have Lewy-related pathology (LRP) (78% versus 45%). In addition, a higher frequency of visual hallucinations was observed in subjects with neocortical LRP than subjects with limbic-, amygdala-, or brainstem-predominant LRP. Although Alzheimer disease with concomitant LRP was the most common neuropathologic subtype in the visual hallucinations-positive group (59%), the frequency of subjects with Alzheimer disease pathology did not differ significantly between those with and without visual hallucinations (74% versus 62%). CONCLUSIONS:: Subjects with visual hallucinations were more likely to have concomitant postural and gait disturbance, additional neuropsychiatric symptoms, and neocortical LRP than subjects without visual hallucinations. Visual hallucinations accompanying dementia have distinct clinical and neuropathologic characteristics that are important for prognosis and clinical management.