Common prescribing patterns should prompt medication review in older adults

Clinical takeaway: When an older adult develops a new symptom or needs another medication, review recently started drugs first. Consider whether the symptom is an adverse effect and whether the original drug can be reduced, changed, or stopped before adding treatment.

A prescribing cascade occurs when a medication adverse effect is mistaken for a new condition and another drug is prescribed to treat it. This often-unrecognized pattern can increase medication burden and expose older adults to additional harms.

In a population-level study published in The BMJ, researchers evaluated 65 expert-identified potentially inappropriate prescribing cascades among nearly 2.3 million community-dwelling adults aged 66 years or older in Ontario, Canada. A cascade was prioritized if the initial drug was widely used, at least 1% of new users subsequently received the second drug, and dispensing patterns showed that the second drug was significantly more likely to follow the first than precede it.

Twenty-four cascades met all three criteria. The most frequent were an iron supplement followed by a laxative (11.9%), a statin followed by a pain reliever (10.9%), and a cholinesterase inhibitor followed by a sleep medication (10.3%). Other high-priority examples included a calcium channel blocker followed by a diuretic, an SGLT2 inhibitor followed by an antifungal, and an NSAID followed by an antihypertensive.

A separate US research letter published in JAMA Network Open provides broader context on medication burden. In nationally representative data, the proportion of adults aged 65 years or older taking at least five prescription drugs nearly doubled, from 21.9% in 1999–2000 to 40.7% in 2017–2020.

Against this backdrop of rising medication burden, the 24 patterns identified in the Ontario study provide practical targets for medication review, but they do not prove that an inappropriate prescribing cascade occurred. The administrative data did not reveal why a second drug was prescribed, and some combinations may be clinically appropriate. When one of these patterns appears, clinicians can ask whether the newer drug is treating an adverse effect, whether a safer or lower-dose alternative exists, and whether the original medication remains necessary.

“This prioritised list could inform system level prescribing and deprescribing initiatives and be integrated into clinical decision support systems,” the study authors concluded.

Source: Rochon PA, et al. (2026 Sep 10) BMJ. Exploring high priority potentially inappropriate prescribing cascades in older adults: population level retrospective cohort study