Visual hallucinations in the elderly: Charles Bonnet Syndrome and dementia

Discover how to recognize Charles Bonnet Syndrome, manage visual hallucinations in dementia patients, and confidently de-escalate anxiety without arguing.

Visual hallucinations and Charles Bonnet Syndrome

When the nights grow longer and there is less bright sunlight, visual hallucinations occur more frequently in the elderly, especially around sunset. We observe this phenomenon mainly when a patient has poor eyesight, particularly in cases of macular degeneration. Interestingly, in many of these instances, the individual remains aware that what they are seeing is not actually real.

This specific medical phenomenon is known as Charles Bonnet Syndrome.

When poor vision causes the brain to stop receiving normal visual stimuli, it begins to fill in the blanks by generating its own vivid images. While it can be startling for family members to witness, understanding that it stems from visual impairment rather than sudden cognitive decline can provide immense peace of mind to caregivers.

Dementia vs. hallucinations: how to respond

Last week, I saw a patient with dementia who experienced a very different kind of hallucination. This gentleman clearly saw seven people sitting in his room directly in front of him. In his opinion, the space was getting a bit too crowded! When I asked where they were, he pointed right at them and began counting them out loud (though he only managed to reach five).

In this scenario, because of his underlying dementia, he truly believed those people were physically present in the room. Fortunately, he was not afraid. When evaluating hallucinations in a loved one, checking for fear or distress should always be your very first step.

There is no direct medical treatment for these visions, but environmental adjustments make a massive difference. Very often when visiting patients, I notice they are sitting in a dim room with only a tiny lamp turned on and all the curtains firmly closed. Maximizing physical light is key.

Another crucial rule to remember when supporting someone with dementia: their truth is the only truth that matters in that moment. You will never win a logical argument, and attempting to correct them will only cause deep frustration for both of you. If they see seven people in the room and are not afraid, simply validate their comfort, change the subject, or calmly say something like: "They will probably leave a bit later."

Note: Sudden hallucinations can also be a primary symptom of delirium caused by an underlying physical issue like a urinary tract infection (UTI). If you are ever unsure, or if your loved one is experiencing severe, unmanageable fear that you cannot decrease, always contact a medical doctor immediately to check for an underlying medical cause.

Caregiver checklist for handling hallucinations

Keep these practical steps in mind next time your loved one sees something that isn't there:

• Assess for fear: Determine immediately if the hallucination is causing them anxiety or distress.
• Maximize the lighting: Turn on bright overhead lights and open the curtains to eliminate shadows.
• Optimize vision: Ensure they are wearing their correct, clean prescription glasses if applicable.
• Avoid correction: Do not try to argue, reason, or convince them that what they see isn't real. Pivot the conversation gently instead.