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. Patients who suffer from other disorders, including tinnitus and hyperacusis, are also at greater risk for the development of musical hallucinations.3,4

Medication use and polypharmacy
Tricyclic antidepressants, such as imipramine, nortriptyline, and clomipramine, have been implicated in musical hallucinations.3-6 It has been hypothesized that anticholinergic effects of these medications can precipitate a chronic delirium, in which there is a predisposition to perceptual disturbances, including musical hallucinations. Often, patients may be taking other medications that have anticholinergic side effects, which are contributing to the problem. Reducing the dosage of tricyclic antidepressants, or preferably discontinuing the drugs, has been associated with improvement in many cases of musical hallucinations.

A thorough review of all of the patient’s medications, including prescription drugs, over-the-counter agents, and herbal supplements, should be performed. The clinician should have a high index of suspicion for agents that have a temporal association with the symptoms, and when the patient is taking multiple medications that may cause drug-drug interactions. Serotonin syndrome, benzodiazepine use, stimulant medications, and many herbal preparations have all been implicated in the development of musical hallucinations.9

Neurologic disorders
Cerebral perfusion defects may be involved in musical hallucinations.4 Decreased blood flow in the temporal lobes, as determined by single-photon emission computed tomography (SPECT) scan of the brain, has been demonstrated in cases of musical hallucinations.2 Tumors, seizures, and strokes in the temporal lobe have also been associated with musical hallucinations.1 Another area of the brain associated with musical hallucinations is the dorsal pons. Tumors of the cerebellopontine angle region are known to present with hearing abnormalities and musical hallucinations. Vascular lesions of the pons have also been found following onset of these symptoms.3,9 Assessment of a patient with musical hallucinations should include a thorough neurologic evaluation, attention to focal findings, head computed tomography (CT) or MRI, and EEG, if warranted by history.

Psychiatric disorders
Musical hallucinations have been identified as an intrusive symptom of obsessive-compulsive disorder, possibly related to hyperactivity in the prefrontal cortex.2 Of all primary psychiatric disorders, obsessive-compulsive disorder has the highest prevalence of musical hallucinations, with 41% of patients describing some periods of these symptoms.10 In another case review, one-third of patients presenting with musical hallucinations were found to suffer from major depressive disorder.3 Functional brain imaging has identified increased activity in the prefrontal lobes during periods of musical hallucinations in patients with mood disorders.

Patients with a history of anxiety disorders may develop musical hallucinations during periods of stress. Schizophrenia, a chronic mental disorder associated with delusions and hallucinations, has been associated with musical symptoms as well.10 In all older adults presenting with a new psychiatric symptom, cognitive loss and dementia must be considered. A cognitive screening exam, such as the Mini-Mental State Examination, should be administered, with follow-up evaluation performed if deficits are identified.

Treatment
Medications should be prescribed based on the nature of the symptoms, the degree of distress, and the presence of comorbid medical or psychiatric disorders.9-11 A diagnosis of a seizure disorder would warrant a trial of anticonvulsant medication, such as phenytoin, carbamazepine, or divalproex.3,7 Patients with major depressive disorder or a history of obsessive-compulsive disorder may benefit from a selective serotonin reuptake inhibitor (SSRI), such as sertraline, citalopram, or escitalopram. Antipsychotic medications have been used to treat musical hallucinations, particularly when the symptoms are distressing or frightening to the patient.9 Atypical antipsychotic agents, including risperidone, olanzapine, quetiapine, and aripiprazole, should be considered over older agents, such as haloperidol, because of greater tolerability and lower incidence of extrapyramidal symptoms.9,10

Behavioral interventions are also useful in the management of hallucinations.12 Some patients may not respond to medication treatment, or may achieve only partial remission of symptoms. The use of sound-generating, “white noise” machines in the home has been shown to reduce the patient’s perception of hallucinations. In addition, use of nature sounds played through headphones often serves both to distract the patient from the hallucinations and to reduce the intensity of the symptoms. Relaxation techniques, such as deep breathing, muscle relaxation, and guided imagery, often reduce the frequency and intensity of symptoms. Teaching the patient to focus on tasks such as engaging in a conversation or activity program, or listening to the radio or television, may help in diminishing awareness of the hallucinations.

OUTCOME OF THE CASE PATIENT
The patient’s hearing aids were repaired, with significant improvement in his hearing and daily functioning. The frequency and intensity of the musical hallucinations remained unchanged. Imipramine was tapered and discontinued. Low-dose trazodone was prescribed to help with sleep. He continued to deny any symptoms of depressed mood and disturbances in appetite or energy. No other psychotic symptoms were present. Given the unremitting nature of his symptoms, no history of loss of consciousness, and normal EEG results, a new seizure disorder seemed unlikely. The patient wanted some relief from his symptoms, and was agreeable to a trial of quetiapine 12.5 mg at bedtime. He reported some improvement in the frequency and intensity of the hallucinations, but complained of nausea and daytime sedation. Quetiapine was discontinued, and olanzapine 2.5 mg once daily was prescribed, with plans to increase the dose to 5 mg daily if tolerated. The patient continues in treatment and has started to use relaxation techniques with guided imagery of nature scenes to help reduce his symptoms.

This work has been funded by the AAGP/Bristol-Myers Squibb Fellowship Program.