In an 83‑year‑old patient with dementia who is currently taking buspirone (buspar) and hydroxyzine but is inconsistent with adherence, how should the medication regimen be managed?

Discontinue Both Medications Due to Poor Adherence

In an 83-year-old patient with dementia who is inconsistently taking buspirone and hydroxyzine, these medications should be discontinued. Poor medication adherence in dementia patients precludes safe ongoing use and prevents assessment of medication effectiveness 1.

Why Discontinuation is Warranted

The 2020 Canadian Consensus Conference on Dementia provides explicit guidance that medication adherence that is poor and precludes safe ongoing use of the medication or inability to assess the effectiveness of the medication is a clear indication for discontinuation 1. This applies to both anxiolytic medications in your patient's regimen.

Specific Concerns with These Medications in Dementia

Buspirone considerations:

• Takes 2-4 weeks to become effective and is only useful in mild to moderate agitation 2
• Inconsistent dosing prevents achieving therapeutic steady-state levels
• The FDA label emphasizes that buspirone requires consistent administration to maintain anxiolytic effects 3
• Without adherence, you cannot determine if lack of benefit is due to the medication or inconsistent use

Hydroxyzine concerns:

• Carries significant anticholinergic properties that should be minimized in older adults 1, 4
• The 2019 AGS Beers Criteria and 2025 expert recommendations strongly advise against anticholinergic medications in dementia due to cognitive impairment risk 4, 5
• Can cause confusion, oversedation, and falls in elderly patients 6
• Inconsistent use increases risk of adverse effects without therapeutic benefit

Practical Deprescribing Approach

Gradual discontinuation protocol:

1. Reduce each medication dose by 50% every 4 weeks until reaching the initial starting dose 1
2. After 4 weeks at starting dose, discontinue completely
3. Monitor for withdrawal symptoms or worsening of behavioral symptoms during taper

Critical caveat: If the patient has clinically meaningful psychotic symptoms, agitation, or aggression that are currently controlled, do not discontinue until these symptoms stabilize 1. However, given inconsistent adherence, you likely cannot attribute symptom control to these medications.

Alternative Management Strategies

Since inconsistent medication adherence is the core problem, address this systematically:

Assess Medication Management Capacity

• Determine if the patient can independently manage medications or needs caregiver assistance 7, 8
• In moderate dementia, caregivers typically must assume all medication responsibilities 8
• At age 83 with dementia, this patient likely requires complete caregiver medication management

If Behavioral Symptoms Require Treatment After Discontinuation

Non-pharmacological interventions first:

• Structured activities, reassurance, socialization 2
• Environmental modifications and caregiver education 2

If pharmacological treatment becomes necessary:

• Consider medications with simpler dosing schedules (once daily)
• Ensure caregiver can directly observe medication administration 8, 9
• Use cognitive aids like pillboxes with caregiver supervision 9
• Avoid medications requiring consistent daily dosing to achieve efficacy (like buspirone)

Transition Medication Responsibility to Caregiver

Key steps for future medication management:

1. Establish clear caregiver responsibility for all medication tasks 8, 9
2. Use automated reminders or pillbox systems with caregiver oversight 7
3. Simplify regimens: prescribe as few medicines as possible, coordinate dosing schedules 7
4. Store medications securely to prevent patient access and reduce error risk 9

Common Pitfalls to Avoid

• Do not continue ineffective medications "just in case" - inconsistent adherence means you cannot assess benefit and only expose the patient to harm
• Do not assume the patient can improve adherence - dementia is progressive; medication management capacity will decline further 8
• Do not add adherence aids without caregiver involvement - pillboxes alone are insufficient in moderate dementia 8
• Do not restart these specific medications - if behavioral symptoms emerge after discontinuation, choose alternatives with better safety profiles and simpler dosing that caregivers can reliably administer