Hydroxyzine Use in Older Adults: Guidelines and Precautions

Hydroxyzine should be avoided in older adults due to high risk of cognitive impairment, sedation, falls, and anticholinergic effects. 1

Risks of Hydroxyzine in Older Adults

Older adults are more sensitive to the psychomotor impairment caused by first-generation antihistamines like hydroxyzine, leading to increased risk of falls, fractures, and subdural hematomas 1
Anticholinergic effects of hydroxyzine are particularly problematic in older adults, including dry mouth, dry eyes, constipation, urinary retention, and increased risk of narrow-angle glaucoma 1
Comorbid conditions common in older adults (increased intraocular pressure, benign prostatic hypertrophy, preexisting cognitive impairment) increase the risks associated with hydroxyzine use 1
Sedating effects persist longer than plasma levels of the medication, causing next-day impairment even when taken at bedtime 1

Second-generation antihistamines are strongly preferred for older adults due to less sedation and fewer anticholinergic effects 1
Fexofenadine, loratadine, and desloratadine at recommended doses do not cause sedation and are safer options 1
If an antihistamine is needed for sleep, the risks of next-morning impairment should be carefully considered, as performance impairment can occur without subjective awareness of drowsiness 1

In moderate renal impairment, the dose of hydroxyzine should be halved 1
Hydroxyzine should be avoided in severe liver disease due to its inappropriate sedating effects 1, 2
For patients with liver impairment, loratadine, desloratadine, or fexofenadine are preferred alternatives 2

If hydroxyzine must be used in older adults (which is generally not recommended), start with the lowest possible dose 3
The FDA label indicates 25 mg three or four times daily for pruritus in adults, but this dose is likely too high for older adults 3
Consider starting at 10-25 mg once daily at bedtime if absolutely necessary, though safer alternatives should be sought 1

While hydroxyzine has shown efficacy for anxiety disorders 4, 5, 6, the risks in older adults generally outweigh the benefits 1
One small study suggested that a single 25 mg dose of hydroxyzine preserved memory and attention in elderly subjects better than lorazepam, but this limited evidence does not outweigh the broader safety concerns 7

First, determine if an antihistamine is truly necessary
If yes, select a second-generation antihistamine (fexofenadine, loratadine, or desloratadine) 1
If sedation is desired for sleep, consider that even nighttime dosing of hydroxyzine can cause next-day impairment 1
For patients with renal or hepatic impairment, further adjust selection based on specific contraindications 1, 2
Monitor closely for adverse effects including sedation, falls, confusion, dry mouth, constipation, and urinary retention 1