In an 80-year-old patient with a prior minor cerebrovascular accident who is now experiencing worsening visual hallucinations and frequent lip‑smacking and chewing movements, what is the appropriate initial management?

Urgent Neurological Evaluation for Possible Seizure Activity

This patient requires immediate EEG monitoring and neurological assessment to rule out non-convulsive status epilepticus, which is the most critical diagnosis to exclude given the combination of prior stroke, visual hallucinations, and automatisms (lip-smacking/chewing movements).

Initial Management Algorithm

Step 1: Emergency Assessment (Within Hours)

• Obtain urgent EEG to detect epileptiform activity at the site of the previous infarct 1
• Check vital signs and assess for acute metabolic derangements
• Review current medications for anticholinergic burden or new additions
• Assess level of consciousness and orientation

Step 2: Determine Clinical Pattern

If EEG shows epileptiform activity:

• Diagnose non-convulsive status epilepticus or complex partial seizures
• Initiate anti-epileptic therapy immediately 1
• Prior CVA is the primary risk factor for late-onset seizures in elderly patients 1

If EEG is normal, assess for atypical features:

The presence of lip-smacking and chewing movements is a critical red flag that distinguishes this from benign visual hallucinations. These automatisms strongly suggest seizure activity rather than Charles Bonnet syndrome 2.

Step 3: Rule Out Other Neurological Diagnoses

Atypical features requiring medical/neuropsychiatric evaluation 2:

• Lack of insight that hallucinations are unreal
• Interactive hallucinations (images that engage with patient)
• Associated neurological signs (the automatisms in this case)
• Continuous rather than episodic symptoms

Consider alternative diagnoses:

• Dementia with Lewy Bodies: Visual hallucinations + Parkinsonian features 3
• Delirium: Acute confusional state with fluctuating consciousness 4, 5
• Recurrent stroke: New vascular event in occipital/temporal regions 6
• Medication toxicity: Anticholinergics, dopaminergics

Step 4: Imaging Decision

Obtain urgent brain MRI without contrast if:

• New or worsening neurological deficits
• Change from baseline since prior CVA
• Concern for new stroke or structural lesion 3

MRI is superior to CT for detecting:

• New ischemic changes
• Occipital cortex lesions (associated with visual hallucinations post-stroke) 6
• Temporal lobe abnormalities

Management Based on Diagnosis

If Seizure Activity Confirmed:

• Start anti-epileptic medication (levetiracetam or lamotrigine preferred in elderly)
• Expect clinical recovery with appropriate treatment 1
• Two clinical presentations exist: episodic psychotic behavior remote from CVA (responds to anticonvulsants) vs. continuous abnormal behavior soon after CVA (variable response) 7

If Charles Bonnet Syndrome (CBS) Considered:

CBS requires all four criteria 2:

1. Recurrent, vivid visual hallucinations
2. Insight that hallucinations are not real
3. No other neurological diagnosis (automatisms violate this)
4. Some degree of vision loss

However, this patient does NOT meet CBS criteria due to the automatisms, which indicate another neurological process.

If Delirium Suspected:

• Identify and treat reversible causes 4, 5
• Reduce or eliminate delirium-inducing medications (steroids, anticholinergics) 4
• Do not use benzodiazepines as initial treatment 4
• For moderate symptoms: oral haloperidol, risperidone, olanzapine, or quetiapine 4
• Maximize non-pharmacologic interventions (reorientation, sleep hygiene) 5

Critical Pitfalls to Avoid

1. Do not dismiss automatisms as benign: Lip-smacking and chewing are classic signs of complex partial seizures, particularly temporal lobe origin
2. Do not assume CBS without meeting all criteria: The presence of automatisms and potentially impaired insight make CBS unlikely 2
3. Do not delay EEG: Non-convulsive status epilepticus is a medical emergency that can present with behavioral changes alone 1
4. Do not start antipsychotics before ruling out seizures: This could mask the underlying diagnosis and delay appropriate treatment

Pharmacological Considerations

If antipsychotic needed after seizures ruled out:

• Low-dose aripiprazole (5 mg daily) has been effective for post-stroke visual hallucinations 8
• Quetiapine or risperidone are alternatives 4
• Avoid typical antipsychotics in elderly due to increased stroke risk

The most likely diagnosis in this case is seizure activity given the automatisms, and anti-epileptic therapy should be initiated once confirmed by EEG 1.