Matilde and Luigi’s hallucinations

Matilde’s story: Matilde, 85 years old, lives by herself since her husband died, but she is autonomous and with no particular cognitive issues. About 7 months ago, she started taking tramadol (100 mg/day) for osteoarticular pain and anal fissures. Matilde undergoes therapies with several more drugs for diabetes (insulin 5 U twice a day) and ischemic cardiomyopathy (carvedilol 50mg/day, furosemide 50 mg/day, telmisartan 80 mg/day, acetylsalicylic acid 100 mg/day, simvastatin 20 mg/day and carnidipine 20 mg/day).
Every year she has the flu vaccine, however this year, 6 days later, she starts hallucinating. Matilde falls out of bed and says her husband pushed her. She is taken to the Emergency Room, where pelvic or rachis fractures are excluded.
Tramadol therapy is discontinued, but Matilde autonomously decides to restart it because of the pain from the fall. Hallucinations reappear, this time even more evident, and Matilde is once again taken to the Emergency Room, where the neurological visit and instrumental exams exclude organic causes: iatrogenic hallucinations by tramadol are therefore hypothesised. The drug is discontinued once again and within 36 hours Matilde is lucid and alert.

Luigi’s story: Luigi, 84 years old, few months ago started taking tramadol (25 mg/day) for lumbar pain, then suspended. He undergoes therapy for diabetes, chronic bronchitis and ischemic cardiomyopathy and takes repaglinide (1.5 mg/day), salmeterol and fluticasone (50µm/500mg twice a day), allopurinol (150 mg/day), digoxin (0.625 mg/day), pramipexole (0.18 mg/day), olmesartan (20 mg/day), pantoprazole (20 mg/day) and diltiazem (240 mg/day).
After the flu vaccine, he experiences discomfort and decides, by himself, to restart taking tramadol for three days. Five days after the vaccination, he starts hallucinating, becomes aggressive and violent and is hospitalized and treated with haloperidol and promazine.
Also in this case, the neurological visit and the CT exclude organic causes for Luigi: tramadol is then discontinued and hallucinations disappear within 24 hours.