Psychoactive Medications and Adverse Outcomes among Older Adults Receiving Hemodialysis

J Am Geriatr Soc. 2019 Mar;67(3):449-454. doi: 10.1111/jgs.15740. Epub 2019 Jan 10.


Background: Guidelines recommend avoidance of several psychoactive medications such as hypnotics in older adults due to their adverse effects. Older patients on hemodialysis may be particularly vulnerable to complications related to use of these agents, but only limited data are available about the risks in this population.

Objectives: To evaluate the association between the use of psychoactive medications and time to first emergency department visit or hospitalization for altered mental status, fall, and fracture among older patients receiving hemodialysis.

Design: Observational cohort study.

Setting: National registry of patients receiving hemodialysis (US Renal Data System).

Participants: A total of 60 007 adults 65 years or older receiving hemodialysis with Medicare Part D coverage in 2011.

Measurements: The predictors were use of sedative-hypnotics and anticholinergic antidepressants (modeled as separate time-varying exposures). The outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, and fracture (modeled separately).

Results: Overall, 17% and 6% used sedative-hypnotics and anticholinergic antidepressants, respectively, in 2011. In multivariable-adjusted Cox regression, anticholinergic antidepressant use was associated with a 25%, 27%, and 39% higher hazard of altered mental status, fall, and fracture, respectively, compared with no use. Use of sedative-hypnotics was not associated with adverse outcomes.

Conclusion: Anticholinergic antidepressants were associated with adverse outcomes in older hemodialysis patients, and alternative treatments should be considered. Sedative-hypnotics were not associated with the risks evaluated in this study, but further investigation of the harms of this class of agents is warranted before their recommendation as a treatment option for insomnia in this population. J Am Geriatr Soc 67:449-454, 2019.

Keywords: US Renal Data System; anticholinergic antidepressants; epidemiology; hemodialysis; sedative-hypnotics.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Accidental Falls* / prevention & control
  • Accidental Falls* / statistics & numerical data
  • Aged
  • Aged, 80 and over
  • Antidepressive Agents* / administration & dosage
  • Antidepressive Agents* / adverse effects
  • Cholinergic Antagonists / administration & dosage
  • Cholinergic Antagonists / adverse effects
  • Consciousness Disorders* / chemically induced
  • Consciousness Disorders* / epidemiology
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Fractures, Bone* / epidemiology
  • Fractures, Bone* / etiology
  • Hospitalization / statistics & numerical data
  • Humans
  • Hypnotics and Sedatives* / administration & dosage
  • Hypnotics and Sedatives* / adverse effects
  • Male
  • Medicare Part D / statistics & numerical data
  • Medication Therapy Management / standards
  • Medication Therapy Management / statistics & numerical data
  • Outcome Assessment, Health Care
  • Renal Dialysis / methods
  • Renal Dialysis / statistics & numerical data*
  • Renal Insufficiency, Chronic / therapy
  • United States / epidemiology


  • Antidepressive Agents
  • Cholinergic Antagonists
  • Hypnotics and Sedatives