For an older adult on chronic dialysis who was recently hospitalized for a suspected pain‑medication overdose and now has disruptive anxiety only during dialysis, should I give a PRN anxiolytic and which agent is safest?

Management of Intradialytic Anxiety in a Patient with Recent Suspected Opioid Overdose

Given the recent suspected pain medication overdose, you should NOT use benzodiazepines as PRN anxiolytics in this patient; instead, prioritize non-pharmacologic interventions first, and if pharmacologic management becomes absolutely necessary, buspirone is the safest option, though it requires scheduled dosing rather than PRN use. 1, 2

Why Benzodiazepines Are Contraindicated in This Patient

Recent Overdose History Creates Unacceptable Risk

• The 2019 American Geriatrics Society Beers Criteria explicitly recommend avoiding benzodiazepines in older adults due to increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. 1
• Benzodiazepines are among the three main drug classes involved in prescription drug overdoses (alongside opioids and antidepressants), making them particularly dangerous in patients with recent overdose history. 3
• The CDC guidelines emphasize that patients with mental health conditions (including anxiety) require "additional caution and increased monitoring" when prescribing controlled substances, and note increased risk for drug overdose among patients with depression. 1

Dialysis-Specific Concerns

• Elderly dialysis patients are significantly more sensitive to benzodiazepine sedative effects, with reduced clearance due to age and renal dysfunction. 1
• Lorazepam's elimination half-life and duration of clinical effect are increased in patients with renal failure, and propylene glycol toxicity can occur at doses as low as 1 mg/kg total daily IV dose. 1
• The pharmacokinetics of benzodiazepines are unpredictable in dialysis patients, with variable removal during dialysis sessions and potential for metabolite accumulation. 4, 5

First-Line Approach: Non-Pharmacologic Interventions

Cognitive and Behavioral Strategies

• Cognitive behavioral therapy has proven efficacy in reducing anxiety in dialysis patients with moderate-quality evidence from meta-analyses. 1, 6
• Implement mindfulness and meditation techniques during dialysis sessions, which lack adverse effects and medication interactions. 1
• Use music therapy during dialysis to reduce anxiety and improve overall symptom burden. 1

Environmental and Procedural Modifications

• Address specific dialysis-related triggers: adjust chair positioning, provide blankets for temperature comfort, ensure adequate pain control during cannulation using topical anesthetics. 1
• Consider manual acupressure, which has shown short-term benefits as an adjuvant intervention for anxiety in dialysis patients. 1
• Ensure adequate dialysis delivery and achievement of target dry weight, as inadequate dialysis contributes to anxiety symptoms. 6

If Pharmacologic Management Becomes Necessary

Safest Option: Buspirone

• Buspirone is metabolized by the liver and does not carry the overdose risk, dependence potential, or respiratory depression associated with benzodiazepines. 7
• However, buspirone requires dose adjustment in severe renal impairment due to increased plasma levels and lengthened half-life. 7
• Critical limitation: Buspirone requires scheduled dosing (typically starting at 7.5 mg twice daily) and takes 2-4 weeks to achieve anxiolytic effect—it cannot be used PRN for acute intradialytic anxiety. 7

Why SSRIs Are Not Appropriate

• Small randomized placebo-controlled trials in hemodialysis patients have shown SSRIs lack consistent benefit over placebo and cause increased adverse effects, particularly gastrointestinal symptoms. 1, 2, 6
• No randomized controlled trials address pharmacologic management of anxiety specifically in kidney failure populations. 1, 2

Practical Algorithm for This Patient

Immediate Management (Today's Dialysis Session)

1. Do NOT administer any PRN benzodiazepine or sedative medication given the recent overdose history. 1
2. Implement environmental modifications: ensure comfortable positioning, provide reassurance, consider music therapy. 1
3. If anxiety becomes severely disruptive and threatens dialysis adequacy, contact the nephrologist to discuss whether the session can be shortened or rescheduled. 1

Short-Term Plan (Next 1-2 Weeks)

1. Initiate cognitive behavioral therapy referral or arrange for social work/psychology consultation. 1, 6
2. Screen for undertreated depression using validated tools (PHQ-9 or GAD-7), as anxiety and depression frequently co-occur in dialysis patients. 1
3. Review all current medications for agents that may worsen anxiety (stimulants, bronchodilators, corticosteroids). 6

Long-Term Plan (If Non-Pharmacologic Approaches Fail)

1. If scheduled anxiolytic becomes necessary after exhausting non-pharmacologic options, start buspirone 7.5 mg twice daily with dose adjustment for renal function. 7
2. Establish close monitoring protocol given the overdose history: weekly check-ins initially, medication reconciliation at each dialysis session. 1
3. Coordinate care with psychiatry or addiction medicine if substance use disorder is suspected. 1

Critical Pitfalls to Avoid

• Never assume a PRN benzodiazepine is safe just because the patient is now in a supervised facility—the overdose history indicates high risk for adverse outcomes with sedating medications. 1
• Do not prescribe lorazepam specifically in dialysis patients due to propylene glycol toxicity risk and unpredictable pharmacokinetics. 1
• Avoid polypharmacy in this already medically complex patient—prioritize interventions without drug interactions. 1
• Do not overlook that "disruptive behavior" during dialysis may represent undertreated pain, inadequate dialysis, or volume overload rather than primary anxiety. 1
• Never initiate opioid or benzodiazepine therapy during acute psychiatric instability or in patients with recent overdose without psychiatric consultation. 1