What is the appropriateness of hydroxyzine (Hydroxyzine) for as-needed anxiety in a 66-year-old patient with potential age-related considerations?

From the Guidelines

Hydroxyzine should be avoided for anxiety in a 66-year-old patient due to its potential for sedation, anticholinergic effects, and increased risk of falls and cognitive impairment in older adults. According to the study by 1, first-generation antihistamines like hydroxyzine are associated with sedative effects, performance impairment, and anticholinergic effects, which can be particularly problematic in older adults. The study also notes that older adults are more sensitive to the psychomotor impairment promoted by first-generation antihistamines and are at increased risk for complications such as fractures and subdural hematomas caused by falls.

Some key points to consider when evaluating the use of hydroxyzine in older adults include:

• Sedation and performance impairment: Hydroxyzine can cause sedation, drowsiness, and performance impairment, which can increase the risk of falls and accidents in older adults 1.
• Anticholinergic effects: Hydroxyzine has anticholinergic properties, which can cause dry mouth, constipation, urinary retention, and blurred vision, and can also increase the risk of confusion, falls, and cognitive impairment in elderly patients 1.
• Alternative treatments: Alternative anxiety treatments that may be safer for older adults include SSRIs like sertraline or escitalopram, or non-pharmacological approaches such as cognitive behavioral therapy 1.
• Monitoring and dosage: If hydroxyzine is prescribed, regular monitoring for side effects and effectiveness is essential, and the medication should be used at the lowest effective dose for the shortest duration necessary 1.

It's also worth noting that the study by 1 recommends avoiding pharmacologic anxiolysis with long- or short-acting sedative medication, especially benzodiazepines, in the elderly, and instead suggests using opioid-sparing multimodal re-anaesthetic medication and preoperative education to reduce patient anxiety. Overall, the potential risks and side effects of hydroxyzine in older adults outweigh its potential benefits, and alternative treatments should be considered.

From the FDA Drug Label

THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS Geriatric Use A determination has not been made whether controlled clinical studies of hydroxyzine included sufficient numbers of subjects aged 65 and over to define a difference in response from younger subjects In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of hydroxyzine and observed closely.

For a 66-year-old patient, caution is advised when using hydroxyzine for as-needed anxiety due to the potential for confusion and over sedation. The patient should be started on a low dose and closely observed. It is also important to consider the patient's renal function and concomitant disease or other drug therapy when selecting a dose 2. Key considerations include:

• Potential for QT prolongation and Torsade de Pointes
• Concomitant use of other CNS depressants or drugs that prolong the QT interval
• Monitoring for signs of acute generalized exanthematous pustulosis (AGEP)
• Avoiding simultaneous use of alcohol or other CNS depressant drugs.

From the Research

Treatment Options for Anxiety in the Elderly

• Benzodiazepines are commonly used to treat anxiety in the elderly, but their use is generally recommended for short periods due to the risk of cumulative toxicity and dependence 3.
• Buspirone is an alternative anxiolytic drug that has been shown to be effective and safe for use in elderly patients, with a similar side effect profile to that in younger patients 4.

Considerations for Benzodiazepine Use

• Long half-life benzodiazepines are not preferred for older patients due to the risk of cumulative toxicity 3.
• Short half-life benzodiazepines, such as lorazepam and alprazolam, may be more toxic than low-potency compounds like oxazepam 3.
• Regular use of benzodiazepines can lead to severe psychological and physical dependence, and withdrawal symptoms can be life-threatening 5.

Alternative Treatment Options

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed medications for generalized anxiety disorder, but their efficacy compared to benzodiazepines is modest to moderate 6.
• Cognitive behavioral therapy (CBT) is also a treatment option for anxiety disorders, and its efficacy can be predicted and indexed by the late positive potential (LPP) during low working memory load 7.

Hydroxyzine for Anxiety

• There is no direct evidence in the provided studies to support the use of hydroxyzine for anxiety in a 66-year-old patient.
• However, the studies suggest that benzodiazepines and buspirone can be effective for treating anxiety in the elderly, and that alternative treatment options like SSRIs, SNRIs, and CBT may also be considered 3, 4, 6.