What would you recommend for itching in an older adult, considering hydroxyzine (hydroxyzine) and Benadryl (diphenhydramine) may affect cognition?

Management of Pruritus in Older Adults

For older adults with pruritus, avoid sedating antihistamines like hydroxyzine and diphenhydramine and instead use emollients, topical steroids, and non-sedating antihistamines as first-line treatments to prevent cognitive impairment and falls. 1, 2

Initial Treatment Approach

First-Line Treatments

1. Emollients and Moisturizers

   • Apply high lipid content moisturizers daily 1
   • Focus on xerosis (dry skin) as it affects >50% of elderly patients 3
   • Use mild, low pH cleansers to avoid further skin irritation

2. Topical Steroids

   • Apply hydrocortisone to affected areas up to 3-4 times daily for 2 weeks 1, 4
   • Helps rule out and treat underlying asteatotic eczema
   • For adults and children over 2 years of age (consult physician for younger patients) 4

3. Non-Sedating Antihistamines

   • Preferred options:
     • Fexofenadine 180 mg (lowest sedation at 1.3%)
     • Loratadine 10 mg (8% sedation potential)
     • Cetirizine 10 mg (mildly sedative) 1, 2

Why Avoid Sedating Antihistamines in Older Adults

First-generation antihistamines (hydroxyzine/Benadryl) should be avoided in elderly patients due to:

• High risk of cognitive impairment (strength of recommendation C) 1
• Significant anticholinergic effects causing confusion, urinary retention, and dry mouth 2
• Increased fall risk (50-80% sedation potential) 2, 5
• Potential for serious adverse events including accidents and cardiac effects 5

Second-Line Options

If first-line treatments fail after 2-4 weeks:

1. Gabapentin

   • May benefit elderly patients with pruritus (strength of recommendation D) 1
   • Particularly helpful for neuropathic itch 3

2. Combination Therapy

   • H1 and H2 antagonists together (e.g., fexofenadine with cimetidine) 1
   • Consider topical menthol as an adjunct for cooling effect 1, 6

3. Topical Doxepin

   • Limited to 8 days of treatment
   • Apply to no more than 10% of body surface area
   • Maximum 12g daily 1

Special Considerations

• Medication Review: Check for pruritus-inducing medications, particularly calcium channel blockers and hydrochlorothiazide 3

• Reassessment: If initial treatment fails, reassess for underlying causes 1

• Referral Criteria: Refer to dermatology if:

  • Diagnostic uncertainty persists
  • Primary care management fails to relieve symptoms
  • Symptoms cause significant distress 1

What to Avoid

• Sedative antihistamines (diphenhydramine, hydroxyzine) 1, 2, 5
• Crotamiton cream (strength of recommendation B) 1
• Topical capsaicin or calamine lotion (strength of recommendation D) 1

By following this algorithm, you can effectively manage pruritus in older adults while minimizing the risk of cognitive impairment and other adverse effects associated with sedating antihistamines.