Jiska Cohen-Mansfield, PhD, ABPP, Department of Health Promotion, School of Public Health and Herczeg Center on Aging, Tel-Aviv University, Tel-Aviv, Israel, and Department of Health Care Sciences and of Prevention and Community Health, George Washington University Medical Center, Washington, DC, USA.

Approximately 20% of older people with dementia manifest visual or auditory hallucinations. In order to effectively diagnose and treat these individuals, the etiology of hallucinations must be addressed; however, there has been very limited research in this area. There is an association between vision loss and hallucinations, and analyses of case studies suggest other potential etiologies. Accordingly, hallucinations can occur when the person with dementia either misinterprets reality, experiences sensory deprivation, is exposed to inappropriate sensory stimulation, has delirium/medical problems, or when his/her behaviour is misinterpreted due to cultural differences with caregivers. Understanding the etiology of hallucinations will assist in developing an appropriate nonpharmacological treatment, which may improve quality of life.
Key words: hallucinations, dementia, etiology, nonpharmacological, treatment.

Svante Östling, MD, PhD, Sahlgrenska Academy at Göteborg University, Institute of Clinical Neuroscience and Physiology, Psychiatry Section, Mölndal, Sweden.

The growing proportion of older adults in the population has increased the interest in psychiatric symptoms and disorders that seriously compromise the quality of life in this age group. Psychotic symptoms are common among both demented and nondemented older adults and demand resources from the social and health care systems. There are different etiologies of these symptoms, and different possible underlying medical contributing illnessess, concomitant medications, dementia, delirium, and psychiatric comorbidities should be identified before a specific antipsychotic treatment is considered.
Key words: psychosis, hallucinations, delusions, paranoid older adults.

Abi V. Rayner MD MPH, Buller Medical Service, Westport, New Zealand.

Psychotic symptoms, hallucinations, and delusions, arising de novo in older adults, represent a major risk factor for the development of dementia, illness, delirium, functional impairment and death. These symptoms and associated behavioural manifestations overlap with depressive disorders and may be signs of cognitive impairment or dementia. Symptoms may be vague or legitimized so that the psychosis is unrecognized by family and physicians. Specific queries regarding the nature of the symptoms and the impact on function will provide diagnostic clues. Several brief assessment tools can be used in primary care, specifically the NPI-Q and Blessed Dementia Scale.
Key words: psychosis, hallucinations, delusions, dementia, depression.

David J Burn, MD, MA, FRCP, Consultant & Senior Lecturer in Neurology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road Newcastle upon Tyne, UK.

Ian G McKeith, MD, FRCPsych, Professor of Old Age Psychiatry, Department of Old Age Psychiatry, Institute for Ageing and Health Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.

Introduction
Parkinsonism is a common problem, particularly in the elderly. One percent of the population over the age of 65 has Parkinson's Disease (PD), rising to 2% over the age of 80. Parkinsonism is also a core feature of dementia with Lewy bodies (DLB), the second most common cause of neurodegenerative dementia, after Alzheimer disease (AD). To differentiate patients with PD who develop cognitive impairment from DLB, Consensus Criteria stipulate that parkinsonism must be present for 12 months or less for a patient with dementia to qualify for a diagnosis of DLB.¹ If the extrapyramidal features are present for longer than this before the dementia develops, the diagnosis is referred to as PD with dementia.

Although parkinsonism occurs in numerous other neurodegenerative diseases, including multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, as well as AD, hallucinations are less common.

Interview with Dr. Michel Panisset

Dr. Michel Panisset is the Director of the Movement Disorder Clinic at the McGill Centre for Studies in Aging, and an Assistant Professor in the Department of Neurology and Neurosurgery at McGill University. He specializes in neurology and movement disorders and is particularly interested in Parkinson's Disease. He is also a member of the Parkinson Study Group. Dr. Panisset kindly agreed to share his knowledge and views on the best methods to control hallucinations in patients suffering from PD.

Q: Do hallucinations constitute a big problem for your patients who suffer from Parkinson's disease? How do these hallucinations affect a patient's wellbeing and daily functioning? Do they affect a patient's compliance with medication?

A: Approximately 20 to 40% of patients with Parkinson's Disease experience hallucinations. When we look at our own data, we find that this number is closer to 40%. So, it is a very significant problem. Hallucinations usually start in patients suffering from a more advanced stage of the disease, who have greater problems with cognition and require more medications. We do not see a strong effect on compliance in this particular subpopulation of patients. Typically, when a patient suffers from cognitive or psychiatric problems, medications are administered with the help of a caregiver.