Clinical Geriatrics

CASE PRESENTATION
A 77-year-old divorced Caucasian man is referred for psychiatric evaluation by his neurologist for a history of new-onset auditory hallucinations. His symptoms consist entirely of well-formed musical hallucinations of songs, including “Tiny Bubbles,” “The Tennessee Waltz,” “Till We Meet Again,” “Amazing Grace,” and “The Star-Spangled Banner.” Many are songs that the patient has played when performing in a band or has heard in church. He saw a neurologist for an evaluation and underwent a magnetic resonance imaging (MRI) scan of the brain. An electroencephalogram (EEG) in both awake and sleep states was performed. No significant abnormalities were noted. The neurologist started the patient on risperidone and titrated the dose up to 1 mg twice daily, with no improvement in the hallucinations. The patient was referred to a psychiatrist for further evaluation and treatment.

The patient arrives for his appointment accompanied by his daughter. He has no prior psychiatric history, although he has taken imipramine 100 mg at bedtime for insomnia every night for more than one year. His medical history is significant for neurofibromatosis and a history of a seizure disorder. The patient underwent placement of a ventriculoperitoneal shunt 20 years ago, with no recurrence in seizures. He suffers from hearing loss, and his hearing aids have not been functioning well.

He reports feeling “a little sad” recently since a friend was hospitalized because of a medical illness. No visual hallucinations, paranoid delusions, or neurovegetative symptoms of depression, such as disturbances in appetite, energy, or sleep, are noted. The patient reports that he began hearing music in his head two months ago. The music starts immediately after he wakes up in the morning and continues until he falls asleep. At first he thought the songs were coming from a neighbor’s apartment, but later he realized that they occur only in his own head. He says that the symptoms are an annoyance and “a bother” that he finds distracting, but they are not frightening and are not associated with command hallucinations.

DISCUSSION
Musical hallucinations in the older adult have been associated with multiple risk factors (Table).1-10 Sensory loss—particularly hearing impairments—as well as medication side effects have been commonly implicated.8,9 Many neurologic and psychiatric conditions have also been found in patients who present with musical hallucinations.3,4,10 Given the diversity of risk factors, thorough medical, hearing, neurologic, and psychiatric evaluations should be included for patients presenting with musical hallucinations. There may well be a complex interplay among all of these factors.9 Treatment should be symptom-focused and may include initiation of psychotropic agents such as antipsychotics, antidepressants, or anticonvulsants.9,11 Behavioral interventions may also be useful in many cases.12 Interdisciplinary collaboration is often necessary to address the patient’s multiple problems. The major domains associated with musical hallucinations are discussed in this article.

Hearing impairments
Cases of musical hallucinations associated with hearing impairment have been reported throughout the literature.3,8,9 With normal hearing, attention to external sensory stimuli prevents previously recorded memories from being released into conscious experience. With hearing loss, external auditory stimuli are reduced, leading to a state of sensory deprivation. As a result, previously recorded auditory memories, such as songs, are “released” in the brain and then experienced as hallucinations.5,11 Correcting hearing impairment may well reduce musical hallucinations by restoring appreciation of external sensory stimuli.