Introduction
Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful.
Methods
A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English.
Results
Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram.
Discussion
The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.
Purpose: To determine whether a pharmacist-driven protocol improves guideline-concordant prescribing of diabetes medications in patients with atherosclerotic cardiovascular disease (ASCVD). Methods: A retrospective pre- and post-intervention study was conducted at a university-based family medicine clinic. A pharmacist-driven protocol was implemented which involved the creation of an algorithm recommending specific diabetes medications in patients with ASCVD. An in-service presentation reviewing the algorithm and process for referral of eligible patients to an appointment with a clinical pharmacist was delivered to providers. Clinical pharmacist appointments focus was on improving diabetes management and initiating cardiovascular risk-reducing medications if appropriate. Results: A total of 234 patients were screened, and 108 met inclusion criteria. Upon completion of patient outreach, 34% were scheduled with a pharmacist. Forty-three percent of patients (16 of 37) attended the appointment. Of those, 31% were initiated on an evidence-based regimen indicated for diabetes and ASCVD. In comparing pre- to post-implementation of the pharmacist-driven protocol, the rate of guideline-concordant prescribing increased by 48% (3.8% to 5.6%). Conclusion: Implementation of a pharmacist-driven protocol can increase guideline-concordant prescribing. However, further exploration of patient- and system-level barriers is necessary to implement such a program more broadly.
PACE participants were prescribed fewer medications and had lower anticholinergic burden, which potentially lowers their risk of adverse effects. These data support the PACE interdisciplinary model by demonstrating the benefit of team care in appropriate use of medications. It provides a potential blueprint to organizations aimed at reducing potentially inappropriate medication prescribing in older adults.
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