What antiarrhythmic (arrhythmia) medications are associated with hallucinations, particularly in older adults or those with a history of neurological disorders?

Antiarrhythmics Associated with Hallucinations

Amiodarone is the primary antiarrhythmic drug associated with hallucinations, with documented cases of new-onset visual and auditory hallucinations that resolve within days of discontinuation. 1

Primary Offender: Amiodarone

Amiodarone causes isolated visual and auditory hallucinations independent of delirium, though this adverse effect remains uncommon and under-recognized in clinical practice. 1

• Visual hallucinations with amiodarone include seeing people or threatening figures (such as a man carrying a gun), while auditory hallucinations consist of music and unintelligible conversations 1
• The temporal relationship is typically rapid, with hallucinations beginning shortly after drug initiation and resolving within 2-3 days of discontinuation 1
• The mechanism remains poorly understood, but psychiatric adverse events from amiodarone are documented despite being rare 1

Secondary Consideration: Beta-Blockers (Metoprolol)

Metoprolol, while not a traditional antiarrhythmic, is used for arrhythmia management and has well-documented cases of visual hallucinations, particularly in older adults. 2

• Metoprolol-induced visual hallucinations typically occur at night and include seeing people in the bedroom, dead individuals, or objects transforming into animals 2
• This adverse effect is significantly under-recognized because patients often dismiss experiences as dreams or feel embarrassed to report them 2
• Hallucinations resolve within 4-7 days after switching to alternative beta-blockers like atenolol 2
• Lipophilic beta-blockers (like metoprolol and propranolol) have greater central nervous system penetration, increasing risk of neuropsychiatric effects 2

Clinical Recognition and Management Algorithm

When evaluating new-onset hallucinations in patients on antiarrhythmics:

1. Obtain detailed medication history focusing on recent initiation or dose changes of amiodarone or beta-blockers 1, 2
2. Rule out delirium by assessing for altered cognition, attention deficits, and fluctuating consciousness 1
3. Exclude depression with psychotic features by evaluating for concurrent depressive symptoms 1
4. Consider temporal relationship: hallucinations beginning shortly after drug initiation strongly suggest drug causation 1, 2
5. Discontinue or switch the offending agent: replace amiodarone with dronedarone or switch metoprolol to atenolol 1, 2
6. Monitor for resolution: expect improvement within 2-7 days if drug-induced 1, 2

Critical Caveats for Older Adults

Older adults are particularly vulnerable to antiarrhythmic-induced hallucinations due to age-related pharmacokinetic changes and polypharmacy. 2

• Patients aged >65 years taking metoprolol for 18 months to years may develop chronic visual hallucinations that persist until drug discontinuation 2
• Healthcare providers frequently fail to recognize this toxicity, attributing hallucinations to concurrent illness or other medications rather than the antiarrhythmic 2
• Patients with neurological disorders or cognitive impairment may have difficulty articulating hallucinatory experiences, leading to delayed recognition 2

Proarrhythmic Context

While hallucinations are the focus, all antiarrhythmic drugs carry significant proarrhythmic risk (≥5% incidence) that can cause life-threatening arrhythmias, making the risk-benefit assessment crucial. 3, 4

• Antiarrhythmic drugs can induce ventricular tachycardia, torsades de pointes, severe bradycardia, or asystole through their electrophysiological effects 3
• Only beta-blockers have demonstrated mortality reduction in arrhythmia management, particularly post-myocardial infarction 4
• The negative inotropic effects and proarrhythmic potential often outweigh benefits except in severely symptomatic patients or those with prognostically important arrhythmias 3