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Tramadol in Elderly/CKD — RACP Adult Medicine MCQ

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ModerateGeriatric MedicineTramadol in Elderly/CKDRACP Adult Medicine

An 82-year-old woman is admitted with a hip fracture. She has moderate chronic kidney disease (eGFR 35 mL/min/1.73 m²). Post-operatively, she develops acute confusion. Her medications include oxycodone 5 mg PRN, regular paracetamol, and tramadol 50 mg TDS. Which medication is most likely contributing to her delirium?

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Correct answer: B — Tramadol

Tramadol is particularly problematic in the elderly and those with CKD. Its active metabolite (O-desmethyltramadol) accumulates in renal impairment, and tramadol has additional serotonergic and noradrenergic activity that lowers the seizure threshold and causes confusion. It is on the Beers Criteria list as potentially inappropriate in older adults. In CKD, tramadol clearance is significantly reduced. Oxycodone at low doses with renal adjustment is generally safer than tramadol in this population.

Reference: AMH – 2025 – Opioid Analgesics; Beers Criteria – 2023 – AGS