Avoid Hydroxyzine in Older Adults Because of Significant Anticholinergic and Sedative Risks

Guideline‑Based Recommendations

The American Geriatrics Society (2015) explicitly recommends avoiding hydroxyzine in older adults because its potent anticholinergic properties increase the risk of delirium, cognitive impairment, and falls. 2
The 2008 rhinitis guidelines state that older adults are especially sensitive to psychomotor impairment from first‑generation antihistamines such as hydroxyzine, leading to a higher incidence of fractures, subdural hematomas, and other anticholinergic adverse effects. 1

Anticholinergic burden: Hydroxyzine adds substantially to cumulative anticholinergic exposure, which is linked to cognitive decline and delirium in the elderly. [3][2]
Sedation and performance impairment: Even when taken at bedtime, hydroxyzine can cause next‑day sedation and impair driving performance—effects that may occur without the patient feeling drowsy. 1
Impaired driving: Use of hydroxyzine worsens driving performance, especially when combined with secondary tasks such as cell‑phone use. 1
Fall risk: The anticholinergic and sedating properties of hydroxyzine markedly increase the likelihood of falls and related injuries (e.g., fractures, subdural hematomas) in older adults. 1

Second‑generation antihistamines (e.g., fexofenadine, loratadine, desloratadine) do not produce sedation at recommended doses and are preferred when antihistaminic effects are needed. 1
Low‑dose short‑term benzodiazepines (e.g., lorazepam 0.25–0.5 mg) may be used only when absolutely necessary, acknowledging their own fall and cognitive risk profile. [4][5]
Acute anxiety or agitation:
- Lorazepam 0.5–1 mg orally (reduce to 0.25–0.5 mg in frail elders). [4][5]
- Haloperidol 0.5–1 mg (reduce to 0.25–0.5 mg in older/frail patients) for delirium with anxiety. [6][4]

Deprescribing approach: In most cases, taper and discontinue hydroxyzine, transitioning to safer alternatives. (Guideline consensus)
If continuation is unavoidable:
- Start with the lowest possible dose (10–25 mg).
- Monitor closely for sedation, confusion, falls, and anticholinergic effects; reassess frequently. 7
Avoid “as‑needed” dosing: Intermittent use still carries significant risk because hydroxyzine’s half‑life and tissue effects persist longer than plasma levels. 1
Avoid polypharmacy with other sedating or anticholinergic agents: Concurrent use dramatically amplifies adverse‑event risk. 3