It’s not uncommon to see patients in long-term care facilities prescribed medications for anxiety, agitation, or insomnia. Two such medications that can raise red flags are Atarax (hydroxyzine) and Ativan (lorazepam). While both can be appropriate in select situations, using them together can create significant challenges for both clinical and nursing staff — and even lead to survey deficiencies if not properly justified or monitored.
Case Scenario
An 86-year-old female resident with dementia and anxiety is prescribed hydroxyzine 25 mg every 8 hours as needed for agitation. Over time, she continues to have periods of restlessness, and the provider adds lorazepam 0.5 mg twice daily as needed for anxiety. The nursing staff now have two PRN medications that target similar symptoms — both sedating, both CNS depressants, and one with anticholinergic potential (hydroxyzine).
From a clinical standpoint, this combination raises multiple concerns. Both agents can cause sedation, confusion, dizziness, and falls — effects that are especially problematic in elderly patients. Hydroxyzine contributes to anticholinergic burden, which can worsen cognition and cause urinary retention, constipation, and dry mouth. Lorazepam contributes to dependence risk, respiratory depression, and worsening of confusion and delirium risk.
From an operational and regulatory standpoint, this situation can quickly become a documentation and compliance nightmare. In long-term care, surveyors scrutinize PRN psychotropic medication use closely. When two PRN medications are ordered for the same indication (for example, “anxiety” or “agitation”), surveyors often cite this as a deficiency under F758 (Unnecessary Drugs). The facility must demonstrate that both medications are clinically justified, monitored for effectiveness, and used in accordance with behavioral documentation and gradual dose reduction (GDR) expectations. Here’s some data we’ve put together in the past on nursing home survey deficiencies.
In addition to the regulatory concern, for nursing staff, the overlap can create confusion. Which PRN should be given first? How should they document which one was tried, its effectiveness, and whether a second PRN was appropriate? Inconsistent documentation can easily lead to a deficiency during a survey, even if care was appropriate.
Clinical Takeaway
- Both Atarax and Ativan are sedating and increase fall risk in older adults.
- Avoid duplicate PRN orders for the same indication — they often lead to unnecessary drug use and compliance issues.
- Review each psychotropic medication for continued need and consider non-drug interventions first.
- Clear, specific documentation and staff education are essential to avoid regulatory deficiencies.
Bottom Line:
While Atarax and Ativan may each have a place in certain cases, using them together in long-term care can cause more harm than good — clinically, operationally, and regulatory-wise. Reviewing PRN orders routinely and tightening up indications can save staff confusion, improve resident safety, and keep your facility off the deficiency radar.
Further Education
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