What is the appropriate protocol for starting Buspar (buspirone) and discontinuing prn (as needed) hydroxyzine in an elderly patient with dementia and anxiety?

Starting Buspirone and Discontinuing PRN Hydroxyzine in Elderly Dementia Patients with Anxiety

Buspirone is not recommended as first-line treatment for anxiety in elderly patients with dementia; instead, start with an SSRI (citalopram 10 mg daily or sertraline 25-50 mg daily) after implementing non-pharmacological interventions, and discontinue hydroxyzine immediately due to its anticholinergic properties that worsen cognition and agitation in dementia patients. 1, 2

Critical First Step: Discontinue Hydroxyzine Immediately

• Hydroxyzine must be stopped now because anticholinergic medications like hydroxyzine worsen agitation and cognitive function in dementia patients 3, 1
• The Mayo Clinic explicitly identifies anticholinergic agents as medications that should be avoided in elderly dementia patients due to their cognitive-impairing effects 3
• No taper is required for PRN hydroxyzine; simply discontinue and do not refill 3

Why Buspirone Is Not the Right Choice

• Buspirone has no established evidence base for anxiety in dementia patients and does not appear in any major geriatric or dementia management guidelines 1, 2
• While buspirone showed efficacy in elderly patients with generalized anxiety disorder in older trials, these studies specifically excluded patients with dementia or significant cognitive impairment 4, 5, 6
• The FDA label confirms buspirone was studied in elderly patients (mean age 70.8 years) but provides no data on dementia populations 7
• Buspirone requires 2-4 weeks to achieve anxiolytic effects, making it unsuitable for acute anxiety management 8

Recommended Treatment Algorithm

Step 1: Implement Non-Pharmacological Interventions First (Required Before Any Medication)

• Identify and treat reversible medical causes: pain assessment, urinary tract infections, constipation, urinary retention, dehydration, and medication side effects 1, 2
• Environmental modifications: ensure adequate lighting, reduce excessive noise, maintain consistent routines, and provide structured daily activities 1, 2
• Communication strategies: use calm tones, simple one-step commands, allow adequate processing time, and provide gentle touch for reassurance 1
• Caregiver education on the "three R's" approach: repeat, reassure, and redirect 2

Step 2: Initiate SSRI as First-Line Pharmacological Treatment

• Citalopram (Celexa): Start 10 mg daily, maximum 40 mg daily 1, 2
• Sertraline (Zoloft): Start 25-50 mg daily, maximum 200 mg daily 1, 2
• SSRIs are the preferred pharmacological option because they significantly improve overall neuropsychiatric symptoms, agitation, and anxiety in dementia patients with minimal anticholinergic side effects 1, 2
• The American Psychiatric Association recommends initiating SSRIs at low dose and titrating to minimum effective dose for chronic agitation and anxiety in dementia 1

Step 3: Assess Response and Adjust

• Evaluate treatment response at 4 weeks using quantitative measures such as the Cohen-Mansfield Agitation Inventory or NPI-Q 1, 2
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1
• Even with positive response, periodically reassess the need for continued medication every 6 months 1, 2

What NOT to Use

• Avoid benzodiazepines (including lorazepam) for routine anxiety management due to risk of tolerance, addiction, cognitive impairment, falls, and paradoxical agitation in 10% of elderly patients 3, 1, 2
• Avoid antipsychotics unless the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed, due to FDA black box warning for increased mortality risk in dementia patients 1, 2
• Avoid all anticholinergic medications including hydroxyzine, diphenhydramine, and oxybutynin as they worsen cognition and agitation 3, 1

Common Pitfalls to Avoid

• Do not start buspirone simply because it is labeled as an anxiolytic; it lacks evidence in dementia populations and takes weeks to work 9, 8
• Do not continue hydroxyzine even on a PRN basis; its anticholinergic burden accumulates and worsens dementia symptoms 3, 1
• Do not skip non-pharmacological interventions; they must be systematically attempted and documented as insufficient before adding medications 1, 2
• Do not use benzodiazepines as first-line even for acute anxiety episodes; reserve them only for severe, dangerous situations requiring immediate intervention 2

Monitoring Requirements

• Monitor for SSRI side effects including nausea, sleep disturbances, and hyponatremia (particularly with citalopram and sertraline) 1
• Assess for falls risk, as all psychotropic medications increase fall risk in elderly patients 3, 1
• Use validated assessment tools to quantify anxiety symptoms at baseline and follow-up 2
• Document specific triggers and patterns of anxiety using ABC (antecedent-behavior-consequence) charting 1