DRUG CASCADES IN ELDERLY CARE, CLINICAL RECOGNITION AND MANAGEMENT
Abstract
Prescribing cascades happen when side effects from one medication in older adults get mistaken for a new health problem, leading to more prescriptions that pile on complications and make polypharmacy worse. This narrative review covers the background, underlying mechanisms, risk factors, and ways to spot them clinically, their impacts, management approaches, prevention steps, and the roles of healthcare teams, based on real-world hospital studies of multimorbid elderly patients taking several medications. Everyday examples include swelling from calcium channel blockers treated with water pills, or raised blood pressure from NSAIDs managed with blood pressure drugs-issues made worse by aging bodies that process medicines differently and multiple health conditions. These cascades often lead to more hospital stays, loss of daily function, and higher death risks tied to too many drugs. Effective management relies on pharmacists guiding medication reviews and safely stopping unneeded drugs to break the cycle, while prevention draws on tools like Beers Criteria, STOP/START guidelines, and educating patients. Teams of doctors, pharmacists, and nurses working together cut down adverse reactions. In busy hospital settings with limited resources, these practical steps can make medications safer and help older adults live better.
Keywords:
Drug cascades, Prescribing cascades, Polypharmacy, Adverse drug reactions, rescribing strategies, Dep, Management, Prescribing guidelines
References
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2. Nguyen PV, Spinelli C. Prescribing cascade in an elderly woman. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada. 2016 May;149(3):122-4.
3. Chen Z, Liu Z, Zeng L, Huang L, Zhang L. Research on prescribing cascades: a scoping review. Frontiers in pharmacology. 2023 Jul 3;14:1147921.
4. Daunt R, McGettigan S, Kelly L, Curtin D, O’Mahony D. Detection of Potential Prescribing Cascades in Multimorbid Older Patients Hospitalised with Acute Illness—An Observational Prospective Prevalence Study: R. Daunt et al. Drugs & aging. 2025 Jun;42(6):535-46.
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6. Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade. Journal of the American Geriatrics Society. 2024 Jun;72(6):1728-40.
7. Doherty AS, Lund LC, Moriarty F, Boland F, Clyne B, Fahey T, Kennelly SP, O’mahony D, Wallace E. Prescribing cascades among older community-dwelling adults: application of prescription sequence symmetry analysis to a national database in Ireland. The Annals of Family Medicine. 2025 Jul 1;23(4):315-24.
8. Tejani AM, Perry TL. Reducing prescribing cascades. African Journal of Primary Health Care & Family Medicine. 2025 Mar 31;17(1):4929.
9. Simonson W, Feinberg JL. Medication-related problems in the elderly: defining the issues and identifying solutions. Drugs & aging. 2005 Jul;22(7):559-69.
10. Daunt R, McGettigan S, Kelly L, Curtin D, O'Mahony D. Detection of Prescribing Cascades in Multimorbid Older Patients Hospitalized with Acute Unselected Illness. Age and Ageing. 2024 Sep;53(Supplement_4):afae178-013.
11. Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade. Journal of the American Geriatrics Society. 2024 Jun;72(6):1728-40.
12. Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Australian Prescriber. 2011 Dec 1;34(6).
13. Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Therapeutic advances in drug safety. 2018 Nov;9(11):639-52.
14. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Jama. 2003 Mar 5;289(9):1107-16.
15. Salvi F, Marchetti A, D’Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug safety. 2012 Jan;35(Suppl 1):29-45.
16. Hickman E, Gillies C, Khunti K, Seidu S. Deprescribing, polypharmacy and prescribing cascades in older people with type 2 diabetes: a focused review. Journal of the Indian Institute of Science. 2023 Jan;103(1):191-204.
17. Mohammad AK, Driessen JH, Hugtenburg JG, Marmorale A, Siegert C, van den Bemt PM, Denig P, Karapinar‐Çarkıt F. Occurrence of Potential Prescribing Cascades After Hospital Discharge: A Cohort Study. Pharmacoepidemiology and Drug Safety. 2026 Jan;35(1):e70305.
18. Coleman JJ, Ferner RE, Evans SJ. Monitoring for adverse drug reactions. British journal of clinical pharmacology. 2006 Apr;61(4):371-8.
19. Dreischulte T, Shahid F, Muth C, Schmiedl S, Haefeli WE. Prescribing cascades: how to detect them, prevent them, and use them appropriately. Deutsches ärzteblatt international. 2022 Nov 4;119(44):745.
20. Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Therapeutic advances in drug safety. 2018 Nov;9(11):639-52.
21. Jones ES, Rayner BL. The importance of guidelines. Cardiovascular Journal of Africa. 2014 Nov;25(6):296.
22. O'Conor R, Eifler M, Russell AM, Opsasnick L, Arvanitis M, Pack A, Curtis L, Benavente JY, Wolf MS. Caregiver involvement in managing medications among older adults with multiple chronic conditions. Journal of the American Geriatrics Society. 2021 Oct;69(10):2916-22.
23. Pereira F, Bieri M, del Rio Carral M, Martins MM, Verloo H. Collaborative medication management for older adults after hospital discharge: a qualitative descriptive study. BMC nursing. 2022 Oct 24;21(1):284.
24. O'Conor R, Eifler M, Russell AM, Opsasnick L, Arvanitis M, Pack A, Curtis L, Benavente JY, Wolf MS. Caregiver involvement in managing medications among older adults with multiple chronic conditions. Journal of the American Geriatrics Society. 2021 Oct;69(10):2916-22.
25. Siddiqua A, Abdullah RK, Kareem NA. Impact of clinical pharmacist intervention towards polypharmacy in elderly population-a systematic study. Research Journal of Pharmacy and Technology. 2019 Jun 1;12(6):2621-7.
26. Jennings AA, Doherty AS, Clyne B, Boland F, Moriarty F, Fahey T, Hally L, Kennelly SP, Wallace E. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study. Age and ageing. 2024 Jun;53(6):afae116.
27. Dalton K, Callaghan R, O'Sullivan N, McCarthy L. Community pharmacists’ awareness, identification, and management of prescribing cascades: A cross-sectional survey. Research in Social and Administrative Pharmacy. 2024 Jun 1;20(6):102-12.
2. Nguyen PV, Spinelli C. Prescribing cascade in an elderly woman. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada. 2016 May;149(3):122-4.
3. Chen Z, Liu Z, Zeng L, Huang L, Zhang L. Research on prescribing cascades: a scoping review. Frontiers in pharmacology. 2023 Jul 3;14:1147921.
4. Daunt R, McGettigan S, Kelly L, Curtin D, O’Mahony D. Detection of Potential Prescribing Cascades in Multimorbid Older Patients Hospitalised with Acute Illness—An Observational Prospective Prevalence Study: R. Daunt et al. Drugs & aging. 2025 Jun;42(6):535-46.
5. Shahid F, Doherty A, Wallace E, Schmiedl S, Alexander GC, Dreischulte T. Prescribing cascades in ambulatory care: a structured synthesis of evidence. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2024 Jan;44(1):87-96.
6. Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade. Journal of the American Geriatrics Society. 2024 Jun;72(6):1728-40.
7. Doherty AS, Lund LC, Moriarty F, Boland F, Clyne B, Fahey T, Kennelly SP, O’mahony D, Wallace E. Prescribing cascades among older community-dwelling adults: application of prescription sequence symmetry analysis to a national database in Ireland. The Annals of Family Medicine. 2025 Jul 1;23(4):315-24.
8. Tejani AM, Perry TL. Reducing prescribing cascades. African Journal of Primary Health Care & Family Medicine. 2025 Mar 31;17(1):4929.
9. Simonson W, Feinberg JL. Medication-related problems in the elderly: defining the issues and identifying solutions. Drugs & aging. 2005 Jul;22(7):559-69.
10. Daunt R, McGettigan S, Kelly L, Curtin D, O'Mahony D. Detection of Prescribing Cascades in Multimorbid Older Patients Hospitalized with Acute Unselected Illness. Age and Ageing. 2024 Sep;53(Supplement_4):afae178-013.
11. Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade. Journal of the American Geriatrics Society. 2024 Jun;72(6):1728-40.
12. Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Australian Prescriber. 2011 Dec 1;34(6).
13. Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Therapeutic advances in drug safety. 2018 Nov;9(11):639-52.
14. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Jama. 2003 Mar 5;289(9):1107-16.
15. Salvi F, Marchetti A, D’Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug safety. 2012 Jan;35(Suppl 1):29-45.
16. Hickman E, Gillies C, Khunti K, Seidu S. Deprescribing, polypharmacy and prescribing cascades in older people with type 2 diabetes: a focused review. Journal of the Indian Institute of Science. 2023 Jan;103(1):191-204.
17. Mohammad AK, Driessen JH, Hugtenburg JG, Marmorale A, Siegert C, van den Bemt PM, Denig P, Karapinar‐Çarkıt F. Occurrence of Potential Prescribing Cascades After Hospital Discharge: A Cohort Study. Pharmacoepidemiology and Drug Safety. 2026 Jan;35(1):e70305.
18. Coleman JJ, Ferner RE, Evans SJ. Monitoring for adverse drug reactions. British journal of clinical pharmacology. 2006 Apr;61(4):371-8.
19. Dreischulte T, Shahid F, Muth C, Schmiedl S, Haefeli WE. Prescribing cascades: how to detect them, prevent them, and use them appropriately. Deutsches ärzteblatt international. 2022 Nov 4;119(44):745.
20. Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Therapeutic advances in drug safety. 2018 Nov;9(11):639-52.
21. Jones ES, Rayner BL. The importance of guidelines. Cardiovascular Journal of Africa. 2014 Nov;25(6):296.
22. O'Conor R, Eifler M, Russell AM, Opsasnick L, Arvanitis M, Pack A, Curtis L, Benavente JY, Wolf MS. Caregiver involvement in managing medications among older adults with multiple chronic conditions. Journal of the American Geriatrics Society. 2021 Oct;69(10):2916-22.
23. Pereira F, Bieri M, del Rio Carral M, Martins MM, Verloo H. Collaborative medication management for older adults after hospital discharge: a qualitative descriptive study. BMC nursing. 2022 Oct 24;21(1):284.
24. O'Conor R, Eifler M, Russell AM, Opsasnick L, Arvanitis M, Pack A, Curtis L, Benavente JY, Wolf MS. Caregiver involvement in managing medications among older adults with multiple chronic conditions. Journal of the American Geriatrics Society. 2021 Oct;69(10):2916-22.
25. Siddiqua A, Abdullah RK, Kareem NA. Impact of clinical pharmacist intervention towards polypharmacy in elderly population-a systematic study. Research Journal of Pharmacy and Technology. 2019 Jun 1;12(6):2621-7.
26. Jennings AA, Doherty AS, Clyne B, Boland F, Moriarty F, Fahey T, Hally L, Kennelly SP, Wallace E. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study. Age and ageing. 2024 Jun;53(6):afae116.
27. Dalton K, Callaghan R, O'Sullivan N, McCarthy L. Community pharmacists’ awareness, identification, and management of prescribing cascades: A cross-sectional survey. Research in Social and Administrative Pharmacy. 2024 Jun 1;20(6):102-12.
Published
19/02/2026
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Polamadi, V. S. C., Chitteti, R., Mogalraj, A., Katakam, P., Afroz, P., & Y, P. C. (2026). DRUG CASCADES IN ELDERLY CARE, CLINICAL RECOGNITION AND MANAGEMENT. Journal of Case Studies and Case Reports, 5(1), 8-14. https://doi.org/10.37022/jcscr.v5i1.809
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