You may think of a cascade as a soothing brook bubbling over some rocks, but a prescription cascade is not as pleasant. The term refers to the treatment of the side-effects of one drug when a new second drug is prescribed. These side-effects can be mistakenly identified as a new condition, and of course this new condition needs a new drug, making a third drug necessary to counteract the side-effects of the second drug, and so on.
Just like dominoes, these prescriptions cascade, and the result may be a hospital visit or nursing home admission.
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At highest risk are older individuals just because they often take more different medications and have more health conditions. Studies have reported that over half of women 65 and older take five or more different prescription medications; 12 per cent of this age group take nine or more.
How common are prescription cascades? No one really knows for sure because they remain underidentified, although you may actually hear news reports about them. For example, a 71-year-old Montreal woman was admitted to the hospital because of a fall. She had been prescribed an antihypertensive for her high blood pressure; then two diuretics or water pills for edema that may have been caused by the antihypertensive; then a drug to combat her overactive bladder and increased trips to the bathroom; and then finally a drug to ease her dry mouth side-effects. All the medications contributed to her dizziness, thereby increasing her risk for the fall. Luckily, the hospital sorted out her medication regime and she returned home.
Often, when an individual is admitted to a nursing home, all their medications are stopped, then started again one by one. This isn’t a cost-saving measure, but an attempt to ensure that the new resident is only taking what they need for their health, as opposed to something to treat a side-effect. As a result, dosages often differ after admission in the hope that side-effects will be reduced.
While the elderly are more often affected, anyone can be at risk especially if they take medications routinely, and almost everyone can benefit from these measures to avoid taking drugs unnecessarily. First, you want to understand exactly why you are taking the medication and what the potential side-effects could be. (Yes, that means you should read the prescription information that your pharmacist gives you!)
Whenever you have a new medication added to your regime, also have your doctor, nurse or pharmacist review your complete medication profile. You’re looking for something that you may not need, something that may be causing you side-effects, or something that may be just as effective in a lower dose. Never be afraid to ask if you could change a drug or its dose. If you see specialists besides your family doctor, make sure that everyone has a copy of your up-to-date medication list. (Don’t forget to include herbal remedies, natural products, and non-prescription medications that you take on a regular basis.)
As you age, your body’s ability to use medication changes and this may mean you need to lower a drug dose or even stop it completely.
A great resource is the Beers’ Criteria. It lists drugs that older adults need to use with caution, together with the reasons why. It’s available online and is easily understood.
One class of side-effects that are especially bothersome the older you get are the anticholinergic side-effects, such as dry mouth, difficulty urinating, constipation, blurred vision, drowsiness, or memory lapses. A wide variety of drugs has these side-effects, including antihistamines, muscle relaxants, overactive bladder drugs, antidepressants, antipsychotics, and drugs used to treat Parkinson’s.
Ideally you want to take the most effective drugs in the lowest effective doses, especially if you are older. Remember too that knowledge is power when it comes to avoiding side-effects and the prescription cascade.
