Ever heard of a prescribing cascade? I hadn’t either—but it’s a real and very serious issue in resident care. A prescribing cascade happens when one medication is used to treat the side effects of another, without recognizing that the second symptom might be a drug reaction instead of a new diagnosis. Older people, especially those on nine or more medications, are at greater risk for this cycle.
So how does it happen? In one recent study, a prescriber misread a resident’s symptoms, assuming it was a new illness rather than an adverse drug reaction (ADR). That led to an unnecessary prescription, starting a chain reaction. These ADRs can show up as things like constipation, dizziness, or swelling—common signs in older adults that are easy to misinterpret.
One of the most common prescribing cascades in the study involved calcium channel blockers used to treat high blood pressure. These can cause ankle swelling, which is then treated with a diuretic—rather than checking to see if the blood pressure drug might be the cause. And that’s just one example. Other medications highlighted in the study are ones your residents might use every day. For instance, benzodiazepines leading to antipsychotic prescriptions, blood pressure meds causing dizziness treated with anti-vertigo drugs, antidepressants causing insomnia followed by sleep aids, or antipsychotics triggering movement disorders treated with Parkinson’s medications.
As noted in the original report from McKnight’s Long-Term Care News, medication side effects can quietly snowball into dangerous cycles. And a national study in Ireland took this further, applying prescription sequence symmetry analysis to confirm how widespread the issue is. You can read that JAMA-published study here.
Medication review time, folks! Bring together your pharmacy provider and attending physicians. Start with residents who are on nine or more medications and work your way through. If nothing concerning shows up, that’s great. But if you do spot a pattern, this study might be the key to improving quality of life for those residents.
Stay well and stay informed!
