Annals of Family Medicine: Irish National Study Reveals Five Medication 'Prescribing Cascades' Putting Older Adults at Potential Risk

PROVIDENCE, R.I., June 11, 2025 /PRNewswire/ -- New research published in Annals of Family Medicine identifies five clinically relevant prescribing cascades in a national sample of more than half a million older adults in Ireland. The findings show how unrecognized drug side effects can trigger extra prescriptions and potentially avoidable harm in primary care.

Prescribing cascades occur when one medication is used to treat or prevent a side effect of another drug. An unintentional cascade can arise when a patient's symptoms are mistaken for a new illness. In that case, the patient not only experiences the original side effect but also faces added risks from the second medication.

The study, funded by the Health Research Board of Ireland, was led by researchers at University College Cork in Ireland. They analyzed national prescription data for 533,464 community-dwelling Irish adults aged 65 years and older, covering prescriptions dispensed between 2017 and 2020. A prescription sequence symmetry analysis was performed with a 365-day window to examine nine expert-defined 'ThinkCascades.' It is important to note that this study examined dispensed prescriptions data only for potential prescribing cascades. There may be alternative explanations as to why patients are prescribed these medications, such as new health conditions.

Key Findings - The Five Prescribing Cascades

Calcium channel blocker leading to diuretic prescribing

This cascade was the most prominent. About 2.6% of those who started a calcium channel blocker, often used to treat high blood pressure, went on to receive a diuretic within one year. The authors estimated one extra diuretic prescription for every 78 patients started on a calcium channel blocker.

Alpha-1-receptor blocker leading to vestibular sedative prescribing

Alpha-1 receptor blockers are used to ease symptoms of an enlarged prostate. About 3% of alpha-1 blocker users went on to receive a vestibular sedative (used to relieve vertigo and dizziness) within one year. The authors estimated one additional vestibular sedative prescription for every 85 patients who start an alpha-1-receptor blocker.

Selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI) leading to sleep agent prescribing

SSRIs and SNRIs are commonly prescribed for depression. Approximately 2.5% of those on a SSRI or SNRI went on to receive a sleep agent prescription within one year. The authors estimated one additional sleep agent prescription for every 115 patients who start a SSRI or SNRI.

Benzodiazepine leading to antipsychotic prescribing

Benzodiazepines are often used to treat anxiety disorders. This cascade appeared in 3.2% of benzodiazepine initiators. The authors estimated one additional antipsychotic prescription for every 242 patients who start a benzodiazepine.

Antipsychotic leading to antiparkinsonian agent prescribing

Antipsychotics can cause movement-related side effects. About 0.4% of antipsychotic users went on to receive an antiparkinsonian agent prescription within one year. The authors estimated one extra antiparkinsonian agent prescription for every 1,644 antipsychotic users.

Three other drug pairs showed significant negative associations, suggesting physicians may already be intentionally avoiding these cascades. These three cascades include a diuretic to overactive bladder medication; benzodiazepine to antidementia agent; and nonsteroidal anti-inflammatory drugs (NSAIDs) to antihypertensive medication.

"An increasing number of medications in older people is strongly associated with an increased risk of medication-related harm and serious adverse drug reactions," the authors write. "For clinicians, considering adverse drug reactions as part of the differential in patients presenting with new symptoms in primary care is an important step in identifying and mitigating the risk of medication-related harm. Furthermore, identifying prescribing cascades and deprescribing when appropriate offers potential to reduce pill counts and associated treatment burden for patients."           

Article Cited: 

Prescribing Cascades Among Older Community- Dwelling Adults: Application of Prescription Sequence Symmetry Analysis to a National Database in Ireland

Ann Sinéad Doherty, PhD; Lars Christian Lund, PhD; Frank Moriarty, PhD; Fiona Boland, PhD; Barbara Clyne, PhD; Tom Fahey, MD; Seán P. Kennelly, PhD; Denis O' Mahony, DSc; Emma Wallace, PhD

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Annals of Family Medicine is an open access, peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals of Family Medicine is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, and the North American Primary Care Research Group. Annals of Family Medicine is published online six times each year, charges no fee for publication, and contains original research from the clinical, biomedical, social, and health services areas, as well as contributions on methodology and theory, selected reviews, essays, and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed for free on the journal's website, www.AnnFamMed.org.

SOURCE Annals of Family Medicine