Hydroxyzine Is Not Appropriate for Anxiety in Elderly Patients
Hydroxyzine should be avoided in elderly patients with anxiety due to significant risks of cognitive impairment, sedation, anticholinergic effects, and falls. 1, 2, 3
Risks of Hydroxyzine in Elderly Patients
Anticholinergic and Sedative Effects
- Hydroxyzine has significant anticholinergic properties and high sedative potential (80%) compared to newer alternatives 2
- The American Geriatrics Society explicitly recommends avoiding hydroxyzine in older adults to prevent delirium (strong recommendation) 1
- FDA labeling specifically cautions that sedating drugs may cause confusion and oversedation in the elderly 3
Cardiovascular Concerns
- Hydroxyzine carries risk of QT prolongation and Torsade de Pointes, particularly concerning in elderly patients who often have pre-existing cardiovascular conditions 3
- Caution is recommended when using hydroxyzine with other medications that prolong QT interval, which are commonly prescribed in older adults 3
Fall Risk
- Commonly used over-the-counter antihistamines like hydroxyzine have very high rates of side effects including cognitive impairment and daytime somnolence 1
- Elderly patients are at significantly higher risk for falls when taking sedating antihistamines 2
Recommended Alternatives for Anxiety in Elderly Patients
First-Line Options
- Antidepressants, particularly SSRIs and SNRIs, are considered first-line treatment for anxiety in elderly patients 4
- SSRIs/SNRIs with favorable pharmacokinetic profiles should be prioritized to minimize drug interactions 4
Second-Line Options
- Non-sedating antihistamines may be considered if antihistamine therapy is needed:
- Fexofenadine (1.3% sedation potential)
- Loratadine (8% sedation potential)
- Cetirizine (mildly sedative but safer than first-generation antihistamines) 2
Other Considerations
- Buspirone may have benefit but lacks robust studies specifically in elderly populations 4
- Benzodiazepines should generally be avoided in elderly patients due to risks similar to hydroxyzine 4
- Mirtazapine and vortioxetine are considered safe treatment options for anxiety in the elderly 4
Special Precautions
Dosing Considerations
- If any medication with sedative properties must be used in elderly patients, dosing should start at the low end of the range 3
- Elderly patients generally require lower doses due to decreased hepatic, renal, or cardiac function 3
Monitoring
- Close observation is required when sedating medications are used in elderly patients 3
- Particular attention should be paid to cognitive function, balance, and urinary symptoms 2
While some older studies suggest hydroxyzine may be effective for anxiety 5, 6, 7 and one small study claimed minimal cognitive effects in elderly patients 8, these findings are outweighed by more recent and robust guidelines specifically advising against hydroxyzine use in the elderly population due to safety concerns 1, 2, 3.