Skip to main content

Prescribing Cascades

  • Chapter
  • First Online:
Optimizing Pharmacotherapy in Older Patients

Part of the book series: Practical Issues in Geriatrics ((PIG))

  • 629 Accesses

Abstract

Prescribing cascades occur when a drug is prescribed to counteract the side-effects of another drug. Cascades may be intentional and appropriate as when laxatives are prescribed to patients receiving opioid analgesics causing constipation or unintentional and inappropriate as when patients are prescribed diuretics caused by prior prescription of calcium channel blockers causing peripheral oedema, which is misinterpreted as heart failure. Theoretically, there is the potential for vast numbers of cascades, depending on the degree of potential side effects of individual medications that could be misinterpreted as new conditions in older people leading to inappropriate secondary cascade prescriptions. However, there are several well-recognized and more common prescribing cascades that prescribers should be aware of when undertaking routine medication review in multimorbid older people with polypharmacy. Drug-induced side effects often present in non-specific ways, such as falls, cognitive impairment and urinary incontinence, that is, typical geriatric syndromes. Therefore, clinicians should always ask themselves whether new clinical problems in older people might be drug induced before proceeding to prescribing additional medication. Prescribing cascades represent a highly important aspect of inappropriate prescribing in older people that should be detectable by using a structured logical approach as described in this chapter. More important is the need to prevent inappropriate cascades from happening in the first place through careful assessment of older patients’ symptoms leading to correct detection of medication adverse effects and appropriate deprescribing.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Rochon PA, Gurwitz JH. Drug therapy. Lancet. 1995;346(8966):32–6.

    Article  CAS  PubMed  Google Scholar 

  2. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778–80.

    Article  PubMed  Google Scholar 

  4. Savage RD, Visentin JD, Bronskill SE, et al. Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Intern Med. 2020;180(5):643–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Read SH, Giannakeas V, Pop P, et al. Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. J Am Geriatr Soc. 2021;69(10):2842–50.

    Article  PubMed  Google Scholar 

  6. Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005;165(7):808–13.

    Article  PubMed  Google Scholar 

  7. Sternberg SA, Petrovic M, Onder G, et al. Identifying key prescribing cascades in older people (iKascade): a transnational initiative on drug safety through a sex and gender lens—rationale and design. Eur Geriatr Med. 2021;12(3):475–83.

    Article  PubMed  Google Scholar 

  8. Choosing Wisely Australia. 5 Things clinicians and consumers should question. Developed by the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists. 2016. http://www.choosingwisely.org.au/recommendations/ascept. Accessed 9 July 2021.

  9. Onder G, Bonassi S, Abbatecola AM, et al. High prevalence of poor quality drug prescribing in older individuals: a nationwide report from the Italian Medicines Agency (AIFA). J Gerontol A Biol Sci Med Sci. 2014;69(4):430–7.

    Article  PubMed  Google Scholar 

  10. Sternberg SA, Guy-Alfandary S, Rochon PA. Prescribing cascades in older adults. CMAJ. 2021;193(6):E215.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Rochon PA, Petrovic M, Cherubini A, et al. Polypharmacy, inappropriate prescribing, and deprescribing in old age:through a sex and gender lens. Lancet Healthy Longev. 2021;2(5):E290–300.

    Article  PubMed  Google Scholar 

  12. Canadian Institute for Health Information. Drug use among seniors in Canada, 2016. Ottawa: CIHI; 2018. https://secure.cihi.ca/free_products/drug-use-among-seniors-2016-en-web.pdf. Accessed 9 July 2021

  13. Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. The rising tide of polypharmacy and drug–drug interactions: population database analysis 1995–2010. BMC Med. 2015;13:74.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Midao L, Giardini A, Menditto E, Kardas P, Costa E. Polypharmacy prevalence among older adults based on the survey of health, ageing and retirement in Europe. Arch Gerontol Geriatr. 2018;78:213–20.

    Article  PubMed  Google Scholar 

  15. Onder G, Liperoti R, Fialova D, et al. Polypharmacy in nursing home in Europe: results from the SHELTER study. J Gerontol A Biol Sci Med Sci. 2012;67(6):698–704.

    Article  PubMed  Google Scholar 

  16. Statistics Canada. 2016 Census of population, statistics Canada catalogue no. 98-400-X2016018. 2019. https://www12.statcan.gc.ca/census-recensement/2016/geo/geosearch-georecherche/ips/index.cfm?q=98-400-X2016018&l=en&g=2016A000011124. Accessed 9 Sept 2021.

  17. Stall NM, Fischer HD, Fung K, et al. Sex-specific differences in end-of-life burdensome interventions and antibiotic therapy in nursing home residents with advanced dementia. JAMA Netw Open. 2019;2(8):e199557.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605–9.

    Article  PubMed  Google Scholar 

  19. Gurwitz JH. The age/gender interface in geriatric pharmacotherapy. J Womens Health (Larchmt). 2005;14(1):68–72.

    Article  PubMed  Google Scholar 

  20. Watson S, Caster O, Rochon PA, den Ruijter H. Reported adverse drug reactions in women and men: aggregated evidence from globally collected individual case reports during half a century. EClinicalMedicine. 2019;17:100188.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Alturki A, Alaama T, Alomran Y, Al-Jedai A, Almudaiheem H, Watfa G. Potentially inappropriate medications in older patients based on beers criteria: a cross-sectional study of a family medicine practice in Saudi Arabia. BJGP Open. 2020;4(1):bjgpopen20X101009.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Rydberg DM, Mejyr S, Loikas D, Schenck-Gustafsson K, von Euler M, Malmström RE. Sex differences in spontaneous reports on adverse drug events for common antihypertensive drugs. Eur J Clin Pharmacol. 2018;74(9):1165–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Sørup FKH, Eriksson R, Westergaard D, Hallas J, Brunak S, Ejdrup AS. Sex differences in text-mined possible adverse drug events associated with drugs for psychosis. J Psychopharmacol (Oxford, England). 2020;34(5):532–9.

    Article  Google Scholar 

  24. Bezerra de Souza DL, Oliveras-Fabregas A, Espelt A, et al. Multimorbidity and its associated factors among adults aged 50 and over: a cross-sectional study in 17 European countries. PLoS One. 2021;16(2):e0246623.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. McCormick A, Charlton J. Morbidity statistics from general practice. In: Fourth national study 1991–1992. OPCS series MB5 no. 3. London: HMSO; 1995.

    Google Scholar 

  26. Cheff R, Hill M, Iveniuk J. Who benefits? Gaps in medication coverage for Ontario workers. Toronto: Wellesley Institute; 2019. https://www.wellesleyinstitute.com/wp-content/uploads/2019/12/Coverage-Gaps-for-Ontario-Workers_EMBARGO_27.11.19.pdf. Accessed 9 July 2021

  27. Mauvais-Jarvis F, Bairey Merz N, Barnes PJ, et al. Sex and gender: modifiers of health, disease, and medicine. Lancet (London, England). 2020;396(10250):565–82.

    Article  PubMed  Google Scholar 

  28. Regitz-Zagrosek V. Sex and gender differences in pharmacology. Berlin: Springer; 2012.

    Book  Google Scholar 

  29. Lega IC, Bronskill SE, Campitelli MA, et al. Sodium glucose cotransporter 2 inhibitors and risk of genital mycotic and urinary tract infection: a population-based study of older women and men with diabetes. Diabetes Obes Metab. 2019;21(11):2394–404.

    Article  CAS  PubMed  Google Scholar 

  30. Rosenberg J, Rochon PA, Gill SS. Unveiling a prescribing cascade in an older man. J Am Geriatr Soc. 2014;62(3):580–1.

    Article  PubMed  Google Scholar 

  31. Frank C, Weir E. Deprescribing for older patients. CMAJ. 2014;186(18):1369–76.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Piggott KL, Mehta N, Wong CL, Rochon PA. Using a clinical process map to identify prescribing cascades in your patient. BMJ. 2020;368:m261.

    Article  PubMed  Google Scholar 

  33. Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Aust Prescr. 2011;34(6):162–6.

    Article  Google Scholar 

  34. Liu PT, Argento VS, Skudlarska BA. Prescribing cascade in an 80-year-old Japanese immigrant. Geriatr Gerontol Int. 2009;9(4):402–4.

    Article  PubMed  Google Scholar 

  35. Rababa M, Al-Ghassani AA, Kovach CR, Dyer EM. Proton pump inhibitors and the prescribing cascade. J Gerontol Nurs. 2016;42(4):23–31.

    Article  PubMed  Google Scholar 

  36. Kwan D, Farrell B. Polypharmcy: optimizing medication use in elderly patients. CGS J CME. 2014;4(1):21–7.

    Google Scholar 

  37. Rochon PA, Stukel TA, Sykora K, et al. Atypical antipsychotics and Parkinsonism. Arch Intern Med. 2005;165(16):1882–8.

    Article  CAS  PubMed  Google Scholar 

  38. Singh S, Cocoros NM, Haynes K, et al. Antidopaminergic–antiparkinsonian medication prescribing cascade in persons with Alzheimer’s disease. J Am Geriatr Soc. 2021;69(5):1328–33.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Singh S, Cocoros NM, Haynes K, et al. Identifying prescribing cascades in Alzheimer’s disease and related dementias: the calcium channel blocker-diuretic prescribing cascade. Pharmacoepidemiol Drug Saf. 2021;30(8):1066–73.

    Article  PubMed  Google Scholar 

  40. Trenaman SC, Bowles SK, Kirkland S, Andrew MK. An examination of three prescribing cascades in a cohort of older adults with dementia. BMC Geriatr. 2021;21(1):297.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Vouri SM, van Tuyl JS, Olsen MA, Xian H, Schootman M. An evaluation of a potential calcium channel blocker-lower-extremity edema-loop diuretic prescribing cascade. J Am Pharm Assoc (2003). 2018;58(5):534–9 e4.

    Article  PubMed  Google Scholar 

  42. Ponte ML, Wachs L, Wachs A, Serra HA. Prescribing cascade. A proposed new way to evaluate it. Medicina (B Aires). 2017;77(1):13–6.

    CAS  PubMed  Google Scholar 

  43. Vouri SM, Chung JM, Binder EF. Successful intervention to mitigate an acetylcholinesterase inhibitor-induced rhinorrhea prescribing cascade: a case report. J Clin Pharm Ther. 2017;42(3):370–1.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Gnon C, Currie J, Trimble J. Are you the victim of a prescribing cascades? Candian deprescribing network. 2020. https://www.deprescribingnetwork.ca/blog/prescribing-cascade. Accessed 28 Sept 2021.

  45. Gill SS, Anderson GM, Fischer HD, et al. Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study. Arch Intern Med. 2009;169(9):867–73.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Paula A. Rochon .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2023 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Sternberg, S.A., Gurwitz, J.H., Rochon, P.A. (2023). Prescribing Cascades. In: Cherubini, A., Mangoni, A.A., O’Mahony, D., Petrovic, M. (eds) Optimizing Pharmacotherapy in Older Patients. Practical Issues in Geriatrics. Springer, Cham. https://doi.org/10.1007/978-3-031-28061-0_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-28061-0_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-28060-3

  • Online ISBN: 978-3-031-28061-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics