Breaking the Cycle: Preventing Prescribing Cascades in Older Adults

In senior living and long-term care settings, medication safety is a shared responsibility. One of the lesser-known risks that can complicate resident care is the prescribing cascade—when a side effect from one medication is mistaken for a new medical condition, leading to the prescription of yet another drug. Over time, this cycle contributes to unnecessary polypharmacy, higher costs, and increased risk of adverse events.

How Prescribing Cascades Happen

Older adults are especially vulnerable because they often take multiple medications for chronic conditions. A single unintended side effect can set off a chain reaction:

• Calcium channel blockers prescribed for hypertension may cause ankle swelling, for which a diuretic is then added.
• GLP-1 receptor agonists such as Ozempic® may lead to constipation, prompting laxatives or anti-nausea medications.
• Antibiotics may lead to probiotics prescribed indefinitely without clear stop dates.
• Sleep aids can pile up—melatonin added to zolpidem added to trazodone—without discontinuing earlier, ineffective therapies.
• Proton pump inhibitors (PPIs), often started in the hospital and then continued long-term, may lead to malabsorption of vitamins and minerals, prompting supplementation with B12, calcium, and magnesium.
• Antipsychotics may cause daytime drowsiness, and then a stimulant such as modafinil is introduced.

What begins as an attempt to manage a medical condition can quickly escalate into a complex medication regimen that creates more problems than it solves.

A Closer Look at Prescribing Cascades 

The Impact on Residents and Communities 

Prescribing cascades don’t just add pills to a resident’s regimen, they can have significant consequences:

• Increased risk of falls, delirium, and hospitalizations
• Heightened exposure to drug–drug interactions and adverse drug events
• Greater likelihood of cognitive impairment or functional decline linked to unnecessary or inappropriate medications

For communities, the impact extends beyond clinical risk. Each additional prescription adds to staff workload: longer med passes, more monitoring, more documentation, and a higher risk of medication errors. The added complexity makes safe medication management in long-term care more difficult and increases compliance and liability risk.

How to Break the Cascade

The good news is that prescribing cascades are preventable. Through collaboration among pharmacists, prescribers, and care staff, residents can remain on the safest, simplest, and most effective regimen possible.

Senior care pharmacists can:

• Conduct comprehensive medication regimen reviews to look for drug-related causes of new symptoms.
• Identify potentially inappropriate drug combinations and recommend clinical interventions and deprescribing where appropriate.
• Flag medications prescribed without a clear stop date or clinical rationale.

In long-term care settings, pharmacists have a 360-degree view of each resident’s full medication regimen, including prescriptions from multiple providers and over-the-counter products, giving them a unique advantage in identifying medication-related risks.

Prescribers can:

• Ask: “Could this new symptom be a side effect?” before adding another drug.
• Consider dose reduction or switching to a safer alternative rather than layering on additional medications.
• Partner with pharmacists to evaluate when deprescribing strategies are appropriate and align regimens with evidence-based guidelines.
• Request an up-to-date list of all medications a resident is receiving, including those prescribed by specialists or other providers, prior to considering a new medication.

Community care staff can:

• Observe and document changes in residents’ conditions, including when symptoms started in relation to new medications.
• Share observations promptly with the clinical team to help connect the dots.
• Reinforce adherence to deprescribing plans when medications are tapered or discontinued.
• Engage with family members in conversations about the purpose and effectiveness of each medication, helping them understand how optimizing medication management can improve safety and quality of life

Warning Signs of a Prescribing Cascade

Clinical staff can watch for red flags that signal a potential prescribing cascade:

• A new diagnosis appearing shortly after a medication change
• Multiple drugs being prescribed to manage the same symptom or condition
• Prolonged use of medications originally intended to be short-term, such as antibiotics, psychotropics, antiemetics, or laxatives
• Residents reporting sudden changes in function, mood, or cognition without another clear explanation

Building a Culture of Prevention

Preventing prescribing cascades is about more than avoiding unnecessary medications—it’s about protecting resident quality of life, improving clinical outcomes, and reducing the burden on care teams. By asking the right questions, leveraging the expertise of the LTC pharmacy team to help keep medication regimens as streamlined as possible, we can break the cycle before it starts.

Resources: Sternberg SA, Guy-Alfandary S, Rochon PA. Prescribing cascades in older adults. CMAJ. 2021 Feb 8;193:E215 Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7954547/pdf/193e215.pdf

By Lori Morgan, RPh, BCGP

Guardian Pharmacy of Missouri