Visual Hallucinations in Long-Term Care

Visual hallucinations have a multitude of causes, ranging from ophthalmologic disease to neurologic, metabolic, iatrogenic, and psychiatric disorders. Although surprisingly common in geriatric practice and in long-term care (LTC) settings, visual hallucinations pose an interesting clinical challenge. Older patients are often reluctant to acknowledge experiencing a symptom they fear could stigmatize them as mentally ill or lead to psychiatric hospitalization, making it difficult for clinicians to establish a diagnosis.^1-5
Because management varies considerably depending on the etiology of the hallucinations, an accurate diagnosis is essential. We report a typical case of visual hallucinations in an elderly man, describing his progression and treatment. This is followed by an overview of the diagnosis and management of visual hallucinations in the LTC setting.

Case Report

A 77-year-old man, who lived at home alone and was rather reclusive, reported having occasional visual hallucinations during the past 3 to 4 years. The hallucinations were purely visual, consisting of cats and dogs in his home. He said the hallucinations were never upsetting and he generally understood that they were not real. His medical history was significant for progressively worsening cataracts; a long history of dysthymia, which was well controlled with sertraline; type 2 diabetes mellitus, with no evidence of retinopathy; peripheral vascular disease; and ischemic cardiomyopathy. His medications were noncontributory to his hallucinations. He had no history of psychosis or dementia and did not appear depressed during the evaluation.

The patient was admitted to our skilled nursing facility. He did relatively well in the subsequent year, although he remained somewhat isolated in his room. Gradually, the hallucinations started to become more prevalent and typically consisted of cats and, more often, birds in his room. He also visualized thin, clear filaments floating in the air. None of the hallucinations were upsetting to him, and they were only visual; he could neither feel nor hear the manifestations. Over time, he became increasingly less able to accept them as unreal. Although the hallucinations never produced any significant functional impairment, he began to buy birdseed and put it in his room for the birds and would occasionally brush unseen filaments off his food before eating. Because the hallucinations had never caused him distress, they were not treated pharmacologically.

Parallel to the increased frequency and progression of the hallucinations, the patient’s visual acuity deteriorated, reaching a minimum level of 20/400 in right eye and 20/80 in the left eye. He subsequently underwent bilateral cataract extractions and intraocular lens implantations, which improved his vision to 20/50 in the right eye and 20/40 in the left eye. After surgery, the visual hallucinations resolved completely. Demonstrating a seeming lack of insight, the patient remained convinced that the departure of the birds and cats in conjunction with his cataract extractions was coincidental. He remained hallucination-free until his death 8 months later from acute myocardial infarction. This patient’s experience with hallucinations appears to have been a typical case of Charles Bonnet syndrome (CBS).

Discussion

Determining the prevalence of visual hallucinations among older adults is difficult because most studies have focused on specific groups of patients, producing data that are not easily generalized to the broader population of older adults or LTC residents. In a study of 122 elderly psychiatric outpatients, 10% reported visual hallucinations.⁶ The authors concluded that advanced age strongly predicted the likelihood of developing visual hallucinations, specifically for patients with dementia.A literature review of patients with Parkinson’s disease found that 8% to 40% of patients developed visual hallucinations during the course of their illness.⁷ This study also reported a close association between advanced age and the incidence of visual hallucinations. According to a recent Australian study involving community-dwelling elders (mean age, 77.7 years), 17.5% of the largely female cohort had CBS-related hallucinations.⁸

Establishing the prevalence of visual hallucinations among older adults is further complicated by the seemingly low rate of patients who report such incidents to physicians. A cross-sectional study of 86 patients with retinal disease found that 15.1% (n=13) had experienced hallucinations during periods of clear consciousness, with episodes lasting from seconds to minutes, yet only two of the affected patients had reported the hallucinations to their physicians.⁹ Some studies have attributed the high incidence of underreporting among older adults to their concerns that the visual hallucinations are symptoms of mental illness, which they fear could lead to stigmatization or more restrictive institutionalization.^1-5

To encourage self-reporting by afflicted patients, proactive, nonjudgmental identification is an essential part of the management strategy. Staff at LTC facilities who are in a position to observe residents regularly should be educated on recognizing the signs of visual hallucinations, the importance of reporting concerns regarding residents suspected of having visual hallucinations, and the need to be reassuring and nonjudgmental when patients report experiencing visual hallucinations.

Differential Diagnosis for Visual Hallucinations

The differential diagnosis for visual hallucinations is broad and encompasses a range of benign to life-threatening conditions. Common causes include delirium, dementia, substance-induced hallucinosis, primary psychiatric illnesses, CBS, and bereavement. Some underlying causes, such as ophthalmologic disease, delirium, and drug-induced hallucinations, are reversible, especially with early identification and definitive treatment. Appropriately determining the source of visual hallucinations in older adults is paramount to avoiding unnecessary pharmacotherapy and mitigating the risks of polypharmacy. Obtaining a thorough patient history, including a comprehensive medical and drug/alcohol history, is essential for making an accurate diagnosis (Table 1).

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Dementia- and Delirium-Related Hallucinations

Dementia is the most common cause of visual hallucinations in older adults,¹⁰ and they can occur with dementia of any etiology. The most common cause of dementia is Alzheimer’s disease, and approximately 18% of patients with Alzheimer’s disease experience visual hallucinations.¹¹ Dementia-related hallucinations are typically non-threatening and may even be comforting. They often involve adults, children, or animals present in the room—the so-called “phantom boarder syndrome.”¹² Although Lewy body dementia (LBD) is less common than Alzheimer’s dementia, nearly 80% of patients with LBD experience visual hallucinations, and these hallucinations usually occur much earlier in the course of the illness.¹³

Visual hallucinations are sometimes subtle, early symptoms of delirium.¹⁴ Delirium-related hallucinations can take any form and are perhaps better described as illusions: misperceptions of actual objects, such as falsely seeing a piece of furniture as a person or an animal. Patients whose delirium is identified early after onset have a better prognosis because early identification allows its underlying cause to be diagnosed and treated promptly. Patients with underlying dementia are at significantly greater risk of developing delirium.^15,16 Common causes of delirium include infections (eg, urinary, respiratory, skin); metabolic disorders, such as dehydration, electrolyte imbalance, end-organ failure, hyperglycemia, hypoglycemia, and hypoxia; cardiovascular conditions, including arrhythmias, heart failure, myocardial infarction, and shock; neurologic disorders, such as head trauma, subdural hematoma, seizures, and stroke; an adverse reaction to drugs, including anticholinergics, sedatives, and opioids; and conditions such as urinary retention and fecal impaction.

Drug-Induced Hallucinations

Use of certain illegal and prescribed substances, intoxication, and substance withdrawal are well-known causes of visual hallucinations.¹⁷ Prescription and over-the-counter medications are common sources of visual hallucinations in older adults. The most frequent offenders are anticholinergic agents, many of which are available over the counter, and dopaminergic agents, such as levodopa and dopamine agonists. Other commonly used drugs known to induce hallucinations in susceptible individuals are corticosteroids, opioids, and antibiotics (including quinolones and carbapenems). Clinicians should also investigate the patient’s use of over-the-counter drugs, herbal preparations, and complementary medications; often, patients and families do not recognize the need to report the use of these agents. The risk of visual hallucinations and other adverse drug reactions corresponds positively to the number of medications taken. Given the high rate of polypharmacy among older adults, drug-drug reactions should be considered when evaluating patients for visual hallucinations.

Although the abuse of alcohol and of prescribed or illicit drugs are probably less common among today’s older adults in the community and in LTC than in younger populations, such abuses do occur, even in seemingly secure LTC facilities. Illicit drugs commonly associated with visual hallucinations include amphetamines, cocaine, hallucinogens (eg, lysergic acid diethylamide), phencyclidine, and cannabis. Hallucinations are also a fairly common idiosyncratic reaction to opioid drug use, whether prescribed or illicit.

With many drugs, withdrawal can produce hallucinations, especially when discontinuing alcohol, sedatives, hypnotics, and anxiolytics. Alcohol withdrawal commonly causes nocturnal visual hallucinations and may even produce hallucinations in patients with an otherwise clear sensorium. Clinicians should keep in mind that older adults often show attenuated autonomic reactivity and that these patients may not experience more typical reactions to alcohol withdrawal, such as tachycardia, hypertension, tremor, and diaphoresis.¹⁷

Hallucinations and Psychiatric Illness

Primary psychiatric conditions such as schizophrenia or mood disorders may produce hallucinations. Although auditory hallucinations are more common with these psychiatric conditions, patients who experience visual hallucinations indicate that they are often complex and bizarre.

Many bereaved individuals have visual hallucinations of a recently deceased loved one, particularly when the deceased was a spouse. Interviews with approximately 300 widowed men and women found that nearly half had hallucinations of their deceased spouse, with visual hallucinations slightly more common than auditory hallucinations.¹⁸ Surviving spouses who were older (aged ≥40 years) when the death occurred were more likely to have hallucinations than those who were younger, and some experienced the hallucinations for a decade or more.¹⁸ Hallucinations of the deceased are typically short and readily recognized as unreal, yet they can nevertheless be upsetting. Some individuals might be worried that they have a serious mental or neurologic illness, but these experiences are benign and are best thought of as a normal part of the bereavement process.

Visual and Neurological Causes

Among older adults considered psychologically and cognitively intact, CBS is a common and benign cause of visual hallucinations, yet it remains underrecognized.^1,19,20 Most patients with CBS have central or ocular visual impairment, and it has been estimated that up to 60% of patients with severe visual loss experience one or more visual hallucinations.²¹ Although macular degeneration is the visual impairment most commonly associated with CBS, any condition that diminishes vision can cause the syndrome.^1,2 Little to no correlation has been observed between the severity of visual impairment and the prevalence of CBS.¹ Patients with CBS demonstrate no evidence of delirium, dementia, or functional psychiatric illness and generally retain their insight to varying degrees.^1,4,22-24

CBS-related hallucinations are purely visual and typically described as vivid and complex.^1,20 The most common subjects are people or animals. Our case patient, who had cataracts and saw cats and birds is a classic example of a CBS patient. The mechanism of CBS is uncertain, but most researchers think it is a deafferentation phenomenon analogous to phantom limb sensation.^1,22,24,25

Various neurological conditions occasionally cause hallucinations, yet they are rarely reported as causes of visual hallucinations in the LTC setting. Patients who experience seizures and migraines occasionally experience visual hallucinations. Sufferers of occipital seizures (these are rare) and migraines usually report elemental (simple) hallucinations consisting of lines, patterns, or simple shapes. Patients having temporal lobe seizures may present with complex images or report unusual visual phenomena (eg, macropsia, micropsia, and autoscopy).^26,27 Rarely, a stroke or other lesion in the midbrain (ie, in the region of the cerebral peduncles) can produce so-called “peduncular hallucinosis,” which usually takes the form of people or animals.²⁸

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Diagnostic Work-up

The onset of visual hallucinations is often frightening to older adults, and they are generally reluctant to admit they are having them. Clinicians who demonstrate lack of awareness or understanding can cause further distress; thus, taking a calm, nonjudgmental approach is of the utmost importance.

As is the case in nearly all areas of medicine, the patient’s history is the most important element of a diagnostic work-up for visual hallucinations. Reviewing the patient’s medical, neurologic, and psychiatric history and conducting a complete review of systems are vital. It is also important to assess what the patient sees during the hallucinations, determine the timing and location of the episodes, and decide whether the hallucination upsets the patient and whether he or she retains insight into the vision’s unreality. Other important elements to determine are recent illnesses or medication changes; any history of falls, head trauma, or seizures; behavioral disturbances; personality changes; current or prior alcohol or illicit drug use; and cognitive decline. It is paramount to thoroughly review all prescription drugs and over-the-counter medications being used. Caregivers should be included in the interview whenever possible because they are often able to offer additional insight on the patient’s problem. Staff at LTC facilities who are in a position to observe residents regularly should be educated on recognizing the signs of visual hallucinations, the importance of reporting concerns about residents suspected of having visual hallucinations, and the need to be reassuring and nonjudgmental when patients report experiencing visual hallucinations.

In patients with visual hallucinations, a full general physical examination should be conducted, with the focus on excluding acute medical illness as a cause of delirium. It is also important to perform thorough neurologic and ophthalmologic examinations. The Confusion Assessment Method (CAM) is a helpful tool when considering delirium in the differential diagnosis.²⁹ Per the CAM, the presence of an acute-onset, fluctuating course; inattention; and either disorganized thinking or an altered level of consciousness suggests the presence of delirium. Cognitive function should be assessed using the Mini-Mental State Examination³⁰ or a similar instrument.

Depending on the clinical picture, further diagnostic workup should be considered. Laboratory tests that may be helpful include a complete blood count; a comprehensive metabolic panel; serology; tests for thyroid-stimulating hormone, human immunodeficiency virus, vitamin B₁₂ deficiency, and folate deficiency; and urinalysis, urine culture, and urine toxicology.

Neuroimaging with cranial computed tomography scanning or magnetic resonance imaging are usually low yield when evaluating visual hallucinations, unless the patient has a focal neurological deficit or a history of head trauma or falls. Testing with electrocardiography, electroencephalography, slit-lamp examination of the eyes, or neuropsychological testing may be considered for select patients. In addition, some patients may require referral to a specialist in psychiatry, neurology, or ophthalmology.

Treatment

In managing visual hallucinations, it is important to approach them from two directions—as a marker of disease and as a potentially distressing symptom. In some cases, the outcome of the diagnostic evaluation makes definitive treatment obvious. For example, treating an underlying cause of a delirium or a primary psychiatric illness, discontinuing an offending medication, providing detoxification for alcohol withdrawal, or correcting a visual deficit may resolve the hallucinations. Many patients are not distressed by their visual hallucinations,^1,12,21,31 however, and may not require any treatment if a serious covert illness is not identified.

For older adults who do require treatment, nonpharmacologic approaches are preferred (Table 2) regardless of the etiology of the visual hallucinations. Nonpharmacologic treatments obviate concerns about potential adverse effects of medications, which are obviously of great concern for the fragile LTC population.³² Patients with CBS, bereavement, or dementia often require little beyond educating the patient or caregiver on the problem and providing reassurance that the diagnosis is not a mental illness; however, some patients experiencing bereavement-related hallucinations may require formal grief counseling.

Patients with visual impairment may benefit from efforts to improve their vision.^1,4,21,24 Such measures might include improving lighting in the home, encouraging the patient to wear corrective lenses, increasing color contrast in the environment, and reducing glare, or, as was the case with our patient, removing cataracts.

Studies suggest increasing social contact reduces visual hallucinations for some patients,^1,4,23,33 and we have found this approach particularly effective for more reclusive patients. Options for increasing socialization in the community setting may include day programs, a change in living arrangements, or simply encouraging a patient to go to a shopping mall or other crowded venue on a regular basis. In the LTC setting, an active, friendly approach by staff is optimal. Such an approach may include strong encouragement to participate in social and recreational activities and outings, encouraging visitors, selecting an appropriate roommate, and conducting a formal evaluation by a recreation therapist. Some patients may also benefit from supportive counseling.

Pharmacological treatments (Table 3) are largely reserved for patients truly distressed by the hallucinations or who are experiencing associated behavioral problems. Medications are only modestly effective at ameliorating visual hallucinations in this population. Often, they only attenuate the patient’s emotional reaction and fail to eliminate the hallucinations.^1,23,24,33 Neuroleptic medications are the mainstay of treatment for symptomatic visual hallucinations.^1,21,24 Second-generation agents are preferred because they have a lower risk of extrapyramidal side effects; however, they may modestly increase the risk of stroke and all-cause mortality in elderly patients with dementia.³²

Patients with LBD and hallucinations associated with treatment for Parkinson’s disease are exquisitely sensitive to the extrapyramidal side effects of neuroleptics, even the second-generation agents.³⁴ Such patients usually tolerate clozapine and quetiapine, but clozapine requires hematologic monitoring due to its potential for inducing agranulocytosis, and it is cumbersome to use. The goal with any of these agents is to use the minimum effective dose to ensure patient comfort and quality of life.¹² Obviously, if the etiology of the hallucinations is treatable, as is the case with delirium, patients should be weaned off a neuroleptic agent as their underlying condition improves. Limited data suggest some agents in other classes may also be useful in managing visual hallucinations, including cholinesterase inhibitors,³⁵ carbamazepine,^36,37 valproic acid,³⁸ gabapentin,³⁹ and ondansetron.⁴⁰

In the LTC facility, managing visual hallucinations is a team effort. Most staff members, especially those in closest contact with the patients, often have limited training in psychopathology and may be taken aback by what appears to be a very serious psychiatric symptom. Educating staff on the commonality of visual hallucinations in this population, the broad differential diagnosis, and the generally good prognosis will equip them with the tools they need to allay patients’ and families’ anxiety over visual hallucinations and to expedite treatment as needed. 

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Conclusion

Visual hallucinations are common in older patients, especially those in the LTC setting. The differential diagnosis of visual hallucinations is broad and frequently complicated by difficulty obtaining the patient’s full cooperation in providing a clear history of symptoms due to fears of receiving a psychiatric diagnosis or of developing dementia. A wide variety of medical problems are known to cause visual hallucinations, including psychiatric, neurologic, iatrogenic, metabolic, and ophthalmologic disorders. Visual hallucinations can be the first sign of delirium stemming from a potentially life-threatening yet undetected condition and should be taken seriously. Early diagnosis and treatment of the underlying cause of visual hallucinations can be lifesaving in some cases. Prompt and accurate diagnosis is especially important for older adults, to prevent the risks of polypharmacy or complications associated with inappropriate management approaches, such as restraints, deconditioning, and social isolation.

The authors report no relevant financial relationships.

References

1. Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual hallucinations in the visually impaired: the Charles Bonnet syndrome. Surv Ophthalmol. 2003;48(1):58-72.

2. Jacob A, Prasad S, Boggild M, Chandratre S. Charles Bonnet syndrome—elderly people and visual hallucinations. BMJ. 2004;328(7455):1552-1554.

3. Gilmour G, Schreiber C, Ewing C. An examination of the relationship between low vision and Charles Bonnet syndrome. Can J Ophthalmol. 2009;44(1):49-52.

4. Schadlu AP, Schadlu R, Shepherd JB. Charles Bonnet syndrome: a review. Curr Opin Ophthalmol. 2009;20(3):219-222.

5. Teeple RC, Caplan JP, Stern TA. Visual hallucinations: differential diagnosis and treatment. Prim Care Companion J Clin Psychiatry. 2009;11(1):26-32.

6. Soeda S, Terao T, Nishimura M, Nakamura J, Iwata N. Aging and visual hallucinations in elderly psychiatric outpatients. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28(2):401-404.

7. Barnes J, David AS. Visual hallucinations in Parkinson’s disease: a review and phenomenological survey. J Neurol Neurosurg Psychiatry. 2001;70(6):727-733.

8. Vukicevic M, Fitzmaurice K. Butterflies and black lacy patterns: the prevalence and characteristics of Charles Bonnet hallucinations in an Australian population. Clin Exp Ophthalmol. 2008;36(7):659-665.

9. Scott IU, Schein OD, Feuer WJ, Folstein MJ. Visual hallucinations in patients with retinal disease. Am J Ophthalmol. 2001;131(5):590-598.

10. Holroyd S. Visual hallucinations in a geriatric psychiatry clinic: prevalence and associated psychiatric diagnoses. J Geriatr Psychiatry Neurol. 1996;9(4):171-175.

11. Ropacki SA, Jeste DV. Epidemiology of and risk factors for psychosis of Alzheimer’s disease: a review of 55 studies published from 1990 to 2003. Am J Psychiatry. 2005; 162(11):2022-2030.

12. Stewart JT. Behavioral and emotional complications of neurologic disorders. In: Noseworthy JH, ed. Neurological Therapeutics: Principles and Practice. 2nd ed. Abingdon, UK: Informa Healthcare, 2006:3207-3222.

13. Gómez-Tortosa E, Ingraham AO, Irizarry MC, Hyman BT. Dementia with Lewy bodies. J Am Geriatr Soc. 1998;46(11):1449-1458.

14. Jackson ML, Ferencz J. Charles Bonnet syndrome: visual loss and hallucinations. CMAJ. 2009;181(3-4):175-176.

15. Francis J. Delirium in older patients. J Am Geriatr Soc. 1992;40(8):829-838.

16. Sandberg O, Gustafson Y, Brännström B, Bucht G. Clinical profile of delirium in older patients. J Am Geriatr Soc. 1999;47(11):1300-1306.

17. Wartenberg AA, Nirenberg TD. Alcohol and other drug abuse in older patients. In: Reichel W, Gallo JJ, Busy-Whitehead J, Delfs JR, Murphy JB, eds. Care of the Elderly: Clinical Aspects of Aging. 4th ed. Baltimore, MD: Williams & Wilkins, 1995:133-141.

18. Dewi Rees W. The hallucinations of widowhood. Br Med J. 1971;4(5778):37-41.

19. Teunisse RJ, Cruysberg JR, Hoefnagels WH, Verbeek AL, Zitman FG. Visual hallucinations in psychologically normal people: Charles Bonnet’s syndrome. Lancet. 1996;347(9004):794-797.

20. Ricard P. Vision loss and visual hallucinations: the Charles Bonnet syndrome. Community Eye Health. 2009;22(69):14.

21. Hartney KE, Catalano G, Catalano MC. Charles Bonnet syndrome: are medications necessary? J Psychiatr Practice. 2011;17(2):137-141.

22. Gold K, Rabins PV. Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry. 1989; 30(1):90-98.

23. Cole MG. Charles Bonnet hallucinations: a case series. Can J Psychiatry. 1992; 37(4):267-270.

24. Rovner BW. The Charles Bonnet syndrome: a review of recent research. Curr Opin Ophthalmol. 2006;17(3):275-277.

25. Ffytche DH. Visual hallucinations in eye disease. Curr Opin Neurol. 2009;22(1):28-35.

26. Kolmel HW. Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry. 1985;48(1):29-38.

27. Santhouse AM, Howard RJ, Ffytche DH. Visual hallucinatory syndromes and the anatomy of the visual brain. Brain. 2000;123(Pt 10):2055-2064.

28. Manford M, Andermann F. Complex visual hallucinations: clinical and neurobiological insights. Brain. 1998;121(Pt 10):1819-1840.

29. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

30. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.

31. Schneider LS. Pharmacologic management of psychosis in dementia. J Clin Psychiatry. 1999;60(suppl 8):54-60.

32. Karim S, Byrne EJ. Treatment of psychosis in elderly people. Advances in Psychiatric Treatment. 2005;11:286-296.

33. Thorpe L. Treatment of psychiatric disorders in late life. Can J Psychiatry. 1997;42(suppl 1):19S-27S.

34. Ballard C, Grace J, McKeith I, Holmes C. Neuroleptic sensitivity in dementia with Lewy bodies and Alzheimer’s disease. Lancet. 1998;351(9108):1032-1033.

35. Ukai S, Yamamoto M, Tanaka M, Takeda M. Treatment of typical Charles Bonnet syndrome with donepezil. Int Clin Psychopharmacol. 2004;19(6):355-357.

36. Hosty G. Charles Bonnet syndrome: a description of two cases. Acta Psychiatr Scand. 1990;82(4):316-317.

37. Stewart JT, Yelton JA. Treatment of organic hallucinosis with carbamazepine. Am J Psychiatry. 1995;152(1):150.

38. Hori H, Terao T, Shiraishi Y, Nakamura J. Treatment of Charles Bonnet syndrome with valproate. Int Clin Psychopharmacol. 2000;15(2):117-119.

39. Paulig M, Mentrup H. Charles Bonnet’s syndrome: complete remission of complex visual hallucinations treated by gabapentin. J Neurol Neurosurg Psychiatry. 2001;70(6):813-814.

40. Zoldan J, Friedberg G, Livneh M, Melamed E. Psychosis in advanced Parkinson’s disease: treatment with ondansetron, a 5-HT3 receptor antagonist. Neurology. 1995;45(7):1305-1308.