Is ordering Hydroxyzine (hydroxyzine) 25mg for a resident with anxiety, altered mental status, and normal renal function (GFR 80) appropriate?

Hydroxyzine 25mg is NOT an appropriate order for a resident with altered mental status

Hydroxyzine should be avoided in elderly patients with altered mental status, as sedating antihistamines can worsen confusion, increase fall risk, and potentially cause or exacerbate delirium. 1, 2

Why This Order is Problematic

Altered Mental Status Requires Different Management

• Altered mental status in elderly patients demands investigation of underlying causes (infection, metabolic derangement, medication effects) rather than symptomatic sedation. 1
• The urinalysis with culture/sensitivity is appropriate given that urinary tract infections are common precipitants of delirium in elderly residents. 1
• Hydroxyzine's sedating and anticholinergic effects can mask the underlying problem and worsen cognitive function. 1, 2

Specific Risks in Elderly Patients with Altered Mental Status

• Sedating drugs cause confusion and oversedation in the elderly; elderly patients are particularly vulnerable to anticholinergic effects. 2
• Hydroxyzine can cause paradoxical agitation, which may worsen rather than improve the clinical picture. 1
• The medication carries risk of QT prolongation, particularly concerning in elderly patients who may have cardiac comorbidities or electrolyte imbalances. 2, 3
• Increased fall risk is a major concern with sedating antihistamines in elderly populations. 1

Renal Function Considerations

• While the GFR of 80 mL/min does not require dose adjustment for hydroxyzine per se, elderly patients with decreased renal function require cautious dosing starting at the low end of the range. 2
• The extent of renal excretion of hydroxyzine has not been fully determined, adding uncertainty in elderly patients. 2

Appropriate Management Algorithm

First-Line Approach for Anxiety with Altered Mental Status

1. Investigate and treat the underlying cause of altered mental status before administering sedating medications. 1
2. Ensure environmental interventions: quiet setting, familiar objects, reorientation, adequate lighting, and family presence when possible. 1
3. Review all current medications for potential contributors to delirium (anticholinergics, benzodiazepines, opioids). 1

If Pharmacologic Management is Necessary

• For agitation in the context of delirium, low-dose antipsychotics are preferred over sedating antihistamines. 1
• Haloperidol 0.25-0.5 mg orally or subcutaneously is appropriate for elderly/frail patients, titrated gradually. 1
• Quetiapine 25 mg orally may be considered as it is less likely to cause extrapyramidal symptoms and has sedating properties. 1
• Benzodiazepines should be reserved for alcohol or benzodiazepine withdrawal, not routine anxiety in altered mental status. 1

For Pure Anxiety Without Altered Mental Status

• If the resident had anxiety WITHOUT altered mental status, hydroxyzine could be considered, but even then: 2, 4
  • Start with lower doses (10-25 mg) in elderly patients 1, 2
  • Monitor closely for sedation and confusion 2
  • Avoid in patients with cardiac risk factors due to QT prolongation risk 2, 3
  • Consider non-sedating alternatives first 1

Critical Safety Concerns

Contraindications in This Clinical Context

• The combination of altered mental status and hydroxyzine creates high risk for worsening delirium, falls, and aspiration. 1, 2
• Hydroxyzine's anticholinergic properties can precipitate or worsen delirium in vulnerable elderly patients. 1, 2
• Cautious use of benzodiazepines or sedating antihistamines may be considered only after delirium workup is complete and other causes are addressed. 1

Documentation and Monitoring Requirements

• If any sedating medication is used, document specific indication, risk-benefit analysis, and monitoring plan. 1
• Monitor for oversedation, paradoxical agitation, falls, and worsening confusion. 1, 2
• Reassess need for medication frequently and discontinue as soon as possible. 1