What medication is suitable for treating hallucinations in a 75-year-old female patient with Chronic Kidney Disease (CKD) stage 4 and impaired renal function?

From the Guidelines

For hallucinations in a 75-year-old female with stage 4 chronic kidney disease (CKD), I recommend starting with a low-dose atypical antipsychotic such as quetiapine 25mg at bedtime, as suggested by the study 1, with careful dose titration based on response and tolerability. When considering medication for hallucinations in this patient population, it's crucial to prioritize medications with a lower risk of adverse effects, particularly those that are less likely to cause extrapyramidal symptoms (EPS) or worsen renal function.

• Key considerations include:
  • The patient's advanced age and stage 4 CKD, which increase the risk of medication side effects and necessitate dose reductions for medications that are partially renally cleared.
  • The underlying cause of hallucinations, which could include delirium, dementia, psychiatric disorders, or medication side effects, and should guide medication choice.
  • The importance of regular monitoring of renal function, metabolic parameters, and extrapyramidal symptoms.
• Non-pharmacological approaches should be implemented concurrently, including:
  • Maintaining a consistent daily routine.
  • Ensuring adequate lighting.
  • Providing orientation cues.
  • Addressing sensory deficits with glasses or hearing aids if needed.
• The goal is to use the lowest effective dose for the shortest duration possible, as elderly patients with kidney disease are particularly vulnerable to medication side effects, including sedation, orthostatic hypotension, falls, and worsening kidney function, as noted in the study 1.

From the Research

Medication for Hallucinations in a 75-year-old Female with CKD Stage 4

• The patient's condition requires careful consideration of the medication's potential impact on kidney function.
• According to 2, risperidone is one of the most commonly prescribed antipsychotics, and its main metabolite, 9-hydroxyrisperidone (9-OH-RIS), is excreted renally.
• The study suggests that kidney function is an important determinant of risperidone clearance, and the dose may need to be reduced by 50% in patients with a GFR below 60 mL/min.
• Another study 3 found that atypical antipsychotic drugs, including risperidone, are associated with an increased risk for acute kidney injury (AKI) and other adverse outcomes in older adults.
• However, a more recent study 4 found that risperidone use may be associated with a decreased risk for kidney function decline in patients with schizophrenia.

Considerations for Medication Selection

• When selecting an antipsychotic medication for a patient with CKD stage 4, it is essential to consider the potential risks and benefits, including the impact on kidney function.
• The study 5 suggests that oral risperidone, clozapine, aripiprazole, ziprasidone, haloperidol, and long-acting risperidone, flupenthixol, and paliperidone may be used in patients undergoing hemodialysis, but the dosing regimen should be carefully considered.
• The patient's age, comorbidities, and overall health status should also be taken into account when selecting a medication.

Potential Medication Options

• Risperidone may be a suitable option, but the dose should be adjusted according to the patient's kidney function, as suggested by 2.
• Other antipsychotic medications, such as aripiprazole, ziprasidone, or olanzapine, may also be considered, but their potential impact on kidney function should be carefully evaluated.
• It is crucial to monitor the patient's kidney function and adjust the medication regimen as needed to minimize the risk of adverse outcomes.