An older adult starts taking medication for pain, then learns their blood pressure has climbed. A second prescription follows, adding another pill to the morning routine. Before they know it, they may be taking one medication to manage the side effects of another.
As patients add more medications to their routine, they and their doctors can lose track of those connections. A new study in The BMJ looked at prescription patterns in nearly 2.3 million Ontario adults aged 66 and older and identified 24 drug combinations that warrant a second look.
"These sequences of events are common but often missed in clinical practice," said lead author Paula Rochon in a press release. "Knowing what medications you are taking, when they were started, and for what indication is important."
How Prescribing Cascades Affect Older Adults
Researchers call this pattern a potentially inappropriate prescribing cascade. In the pain medication example, nonsteroidal anti-inflammatory drugs, or NSAIDs, can raise blood pressure, leading to another prescription to bring it down.
For older adults taking several drugs for different conditions, working out where a new symptom came from can be difficult. Some suspected side effects appear soon after treatment begins, while others can take months, making the connection trickier to recognize.
Rochon directs research at Sinai Health’s Weston and O’Born Centre for Mature Women’s Health in Toronto. The paper highlights the fact that older women tend to take more medications and experience more harmful side effects as a particular concern. However, the study found that for most drug pairs, the link between starting the first and second medication was about as strong in men as in women.
Explore All OptionsTo help prescribers know which combinations to look for, the team started with 65 possible cascades identified in earlier research by 12 international experts in prescribing and older adults’ care.
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The Drug Combinations That Stood Out
Using prescription data from ICES, Ontario’s health data institute, the researchers looked at new prescriptions during 2022 and 2023. Everyone in the study was living outside a long-term care home when the study began.
For each possible cascade, they checked how many people used the first drug and how often a second was added within a year. They also compared how often people started the drugs in that order rather than the other way around, adjusting for changes in prescribing over time. This helped them narrow the list to 24 combinations.
Among people starting iron supplements, 11.9 percent received a laxative prescription within a year. Among those starting statins, 10.9 percent later received a pain reliever. These two sequences had the highest rates among the 65 examined.
Those prescription patterns don’t necessarily mean the second drug was unnecessary. The records couldn’t show whether it was treating a side effect or a separate health problem.
Checking How a New Pill Entered the Routine
Finding a possible cascade gives the person prescribing the drugs a reason to take another look at the first medication. A lower dose or a different treatment might help, or the drug may no longer be needed. In other cases, treating a known side effect may allow a patient to keep taking a medicine they need.
Avoiding an unnecessary prescription could also save patients and health systems money. Pharmacists could work more closely with prescribers to review patients’ medications, while software could flag a possible cascade before another drug is added.
“Our concern is that so often these conversations between the health care prescriber and the patient are being missed, so people don’t recognize the sequences of events and that they are connected to one another,” Rochon said in the press release.
This article is not offering medical advice and should be used for informational purposes only.
Article Sources
Our writers at Discovermagazine.com use peer-reviewed studies and high-quality sources for our articles, and our editors review for scientific accuracy and editorial standards. Review the sources used below for this article:
- This article references information from a study published in The BMJ: Exploring high priority potentially inappropriate prescribing cascades in older adults: population level retrospective cohort study
