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. 2022 Oct;39(10):829-840.
doi: 10.1007/s40266-022-00964-9. Epub 2022 Sep 15.

ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People

Lisa M McCarthy  1   2   3 , Rachel Savage  4   5 , Kieran Dalton  6 , Robin Mason  4   7 , Joyce Li  4 , Andrea Lawson  4 , Wei Wu  4 , Shelley A Sternberg  8 , Stephen Byrne  6 , Mirko Petrovic  9 , Graziano Onder  10 , Antonio Cherubini  11 , Denis O'Mahony  12 , Jerry H Gurwitz  13 , Francesco Pegreffi  14 , Paula A Rochon  4   5   15   16
Affiliations

ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People

Lisa M McCarthy et al. Drugs Aging. 2022 Oct.

Abstract

Background and objective: Prescribing cascades occur when a drug is prescribed to manage side effects of another drug, typically when a side effect is misinterpreted as a new condition. A consensus list of clinically important prescribing cascades that adversely affect older persons' health (i.e., where risks of the prescribing cascade usually exceed benefits) was developed to help identify, prevent, and manage prescribing cascades.

Methods: Three rounds of a modified Delphi process were conducted with a multidisciplinary panel of 38 clinicians from six countries with expertise in geriatric pharmacotherapy. The clinical importance of 139 prescribing cascades was assessed in Round 1. Cascades highly rated by ≥ 70% of panelists were included in subsequent rounds. Factors influencing ratings in Rounds 1 and 3 were categorized. After three Delphi rounds, highly rated prescribing cascades were reviewed by the study team to determine the final list of clinically important cascades consistent with potentially inappropriate prescribing.

Results: After three rounds, 13 prescribing cascades were highly rated by panelists. Following a study team review, the final tool includes nine clinically important prescribing cascades consistent with potentially inappropriate prescribing. Panelists reported that their ratings were influenced by many factors (e.g., how commonly they encountered the medications involved and the cascade itself, the severity of side effects, availability of alternatives). The relative importance of these factors in determining clinical importance varied by panelist.

Conclusions: A nine-item consensus-based list of clinically important prescribing cascades, representing potentially inappropriate prescribing, was developed. Panelists' decisions about what constituted a clinically important prescribing cascade were multi-factorial. This tool not only raises awareness about these cascades but will also help clinicians recognize these and other important prescribing cascades. This list contributes to the prevention and management of polypharmacy and medication-related harm in older people.

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Conflict of interest statement

The authors have no conflicts of interest that are directly relevant to the content of this study.

Figures

Fig. 1
Fig. 1
Study phases
Fig. 2
Fig. 2
Definition and clinical considerations for clinically important prescribing cascades as presented to Round 3 panelists
See this image and copyright information in PMC

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