I’m often presented with situations where an elderly patient is experiencing new-onset hallucinations. As a pharmacist, my primary focus is to look at the medication list and identify if any drug could potentially be the culprit. Here’s my list of medications that can cause drug-induced hallucinations.
Dopamine Agonists and Derivatives
Dopamine agonists (such as pramipexole and ropinirole) and carbidopa/levodopa (Sinemet) can cause hallucinations because they increase dopaminergic activity within the central nervous system (excellent board exam nugget). While this enhanced dopamine signaling helps improve the motor symptoms of Parkinson’s disease, it can also overstimulate brain pathways involved in perception and cognition, leading to visual hallucinations, vivid dreams, or even delusions. This is usually the first medication class I suspect when a patient has new-onset hallucinations.
Anticholinergics
Strongly anticholinergic medications such as benztropine, diphenhydramine, oxybutynin, and others have the potential to cause hallucinations. This is typically associated with delirium and confusion. If these symptoms are present in addition to the hallucinations, there is a higher likelihood that anticholinergic action may be causing the issues.
Corticosteroids
Corticosteroids have been associated with hallucinations. It usually isn’t something that is very common at the dosages I see utilized for asthma, COPD, and pain syndromes in our geriatric patients, so I don’t usually highly suspect this to be the cause, but it is a good one to remember, particularly if the provider is using aggressive doses of corticosteroids.
Benzo’s and Z-Drugs
Benzodiazepines and Z-Drugs like zolpidem have been associated with causing hallucinations. Keep in mind that this can be due to the medication itself, but may also be caused by withdrawal. Be aware of long-time benzo users who have abruptly discontinued or run out of their prescription.
Digoxin Toxicity
Older patients and those with worsening renal impairment are more likely to experience significant digoxin toxicity that could lead to hallucinations and other central nervous system concerns. Visual hallucinations are most commonly reported, and this can be associated with yellow/green visual changes.
Fluoroquinolones
Fluoroquinolone antibiotics, including ciprofloxacin and levofloxacin, have been associated with central nervous system adverse effects, including hallucinations, confusion, agitation, and psychosis. These reactions are thought to result from inhibition of GABA activity and increased excitatory neurotransmission within the brain. Older adults, patients with renal impairment, and those with preexisting neurologic disorders or concomitant CNS-active medications are at the greatest risk for these adverse effects.
Illicit Medications
Drugs like ketamine, cannabis, LSD, and stimulants all can be associated with causing hallucinations and should not be ignored as a potential cause of hallucinations. While this doesn’t happen very often in the controlled environments that I consult in, it should not be ignored!
I hope this list of causes of drug-induced hallucinations helps you in your practice!
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