Hydroxyzine (Vistaril) Dosing for Geriatric Anxiety
For geriatric patients with anxiety, hydroxyzine should be started at 25 mg three to four times daily (50-100 mg total daily dose divided), which represents 25-50% of the standard adult dose, though benzodiazepines like lorazepam are more strongly supported by current guidelines as first-line treatment. 1
FDA-Approved Dosing
The FDA label for hydroxyzine specifies the following for anxiety in adults: 50-100 mg four times daily. 1 However, this standard adult dosing requires significant reduction in elderly patients due to age-related pharmacokinetic and pharmacodynamic changes. 2
Geriatric Dosing Principles
Start at 25-50% of the standard adult dose in elderly patients, which translates to approximately 25 mg three to four times daily (total daily dose 50-100 mg divided). 2
Titrate cautiously and slowly based on individual response and tolerability, as older patients are at increased risk for adverse effects including sedation, dizziness, and anticholinergic effects. 3, 2
Assess response after 1 week of scheduled dosing, which makes PRN (as-needed) use less optimal for titration purposes. 4
Important Clinical Considerations
Guideline-Recommended Alternatives
NICE guidelines recommend benzodiazepines as first-line pharmacological treatment for acute anxiety in elderly patients, specifically lorazepam 0.25-0.5 mg orally (maximum 2 mg in 24 hours for elderly/debilitated patients). 3, 5, 6
Hydroxyzine lacks strong guideline support compared to benzodiazepines when benzodiazepines are appropriate and not contraindicated. 4
Antidepressants (SSRIs/SNRIs) are considered first-line for chronic anxiety disorders in the elderly, with better evidence for long-term use than hydroxyzine. 7
Common Pitfalls
Avoid using hydroxyzine as first-line when more evidence-based options like SSRIs or carefully dosed benzodiazepines are available and appropriate. 4, 7
Monitor for excessive sedation and anticholinergic effects (dry mouth, constipation, urinary retention, confusion), which are particularly problematic in elderly patients. 2
Be aware that hydroxyzine's efficacy evidence is limited - a Cochrane review found it more effective than placebo but noted high risk of bias in available studies and could not recommend it as reliable first-line treatment. 8
Address reversible causes of anxiety first before initiating any pharmacological treatment, including exploring patient concerns, ensuring effective communication, and treating underlying medical conditions. 3, 6
Tolerability Profile
Hydroxyzine causes more drowsiness/sleepiness compared to other anxiolytic agents, which increases fall risk in elderly patients. 8
The medication is generally acceptable/tolerable when compared to placebo in terms of study completion rates, though sedation remains a concern. 8
Practical Dosing Algorithm
Initial dose: 25 mg orally three times daily (total 75 mg/day) for most geriatric patients. 1, 2
If well-tolerated after 1 week, may increase to 25 mg four times daily (total 100 mg/day). 4, 1
Maximum geriatric dose should not exceed 100 mg daily in divided doses without careful monitoring and compelling clinical indication. 1, 2
Consider switching to guideline-recommended alternatives (lorazepam 0.25-0.5 mg or SSRIs) if response is inadequate after appropriate trial. 3, 5, 7