Taken from Chapter 8, “Deprescribing” from the book, “Live Young, Two Times Longer”.

Prescribing cascades

In the last few years, following this almost chronic polypharmacy which our elderly are victims to, the medical world has started to realize that several drugs are capable of causing what are commonly called prescribing cascades:

  • medication no.1 prescribed for a specific indication can cause an undesirable effect which, in certain cases, will be interpreted as a new pathology and for which one will prescribe,
  • medication no.2 which, too, will cause one or more undesirable effects which must be treated by medication no.3,
  • And so on.

Although the concept of a drug cascade was first mentioned some 20 years ago, the concept is not familiar to many people, including some healthcare professionals. It was only in the last three or four years that the notion began to spread on a larger scale. Any doctor or pharmacist with any experience will tell you that these are things that you come across on a regular basis. For example:

  • A patient is prescribed a thiazide diuretic for edema or hypertension.
  • Subsequently, he may show signs of hypokalemia (a decrease in potassium concentration below an acceptable level), which could lead to heart complications. We must therefore prescribe a potassium supplement.
  • This potassium supplement can cause digestive problems, to peptic ulcer.
  • So the prescriber will have no choice but to protect the patient’s stomach with a PPI (proton pump inhibitor such as omeprazole, pantoprazole or esomeprazole).
  • One could go on assuming that this PPI could cause diarrhea for which they would be given a prescription for loperamide, and the cascade could go on almost indefinitely.

It can be understood here that from a single pathology and a single prescription and necessary medication, that the patient will end up consuming three or four more.

Prevention from prescribing cascades

In general, the prescribing cascade is detected when a problematic situation arises: a fall, hospitalization, a new prescription, and new side effects. But would it be possible to intervene upstream? Probably.

Healthcare professionals now have scientific tables to help them determine the algorithm questions or interventions that can and should be implemented. The first principle would be to question the patient on the side effects, particularly after the prescription of a new drug. Seniors are often uncomfortable or embarrassed to ask questions to health care professionals; they don’t want to “disturb”. It is therefore our duty to ask questions and to tell those closest to us, to not hesitate in reporting unusual effects in elderly loved ones: dizziness, cramps, hallucinations, insomnia, swelling of the extremities, incontinence, nausea, and cough. In short, any change considered abnormal in the patient.

Starting a treatment with a lower dose, and gradually increasing it, is an example of an approach that we pharmacists are seeing more and more often. Prescriptions with “steps” are becoming more common.

It is also part of the routine for pharmacists to provide written information to the patient to warn them of the possible side effects of a new drug. But nothing beats our vigilance and our availability towards our patients.

Major changes in mentality will have to occur in the coming years to reflect this new concept of medication management in the elderly. It is clear that an irreversible turn is now commencing:

  • Multiple deprescribing algorithms are now available to healthcare professionals, including deprescribing PPIs, antipsychotics, antihyperglycemics, or benzodiazepines which, by the way, are probably the first class of drugs that should be cut or stopped in elderly patients, given the questionable risk/benefit ratio.
  • Older patients are increasingly talking to their doctors and pharmacists, and are asking more frequently than before, for a reduction in their medication.
  • Let’s never forget that we need patient involvement to achieve deprescribing harmoniously.
  • More and more non-pharmacological means are available and can help with the reduction of doses or the discontinuation of certain drugs. Psychological care and in particular, cognitive behavioral therapy have been fairly successful.
  • There is even a Canadian Deprescribing Network (Deprescribing.org), a group firmly committed and funded by the Canadian Research Institute for Health. Its activities started in January 2015 and its declared objective is to contribute to promoting health by reducing the damage linked to the use of inappropriate medicines, therefore by reducing their prescription and by deprescribing.

To conclude, here is the sentence that probably best sums up the way prescribers should think about prescription in the elderly: “Start slowly and continue slowly.”