The Prescribing Cascade
My sister-in-law has a good friend, Carol, who is 75 years old and takes 15 prescription medicines, not counting her multivitamin or blood glucose test strips. They were concerned that Carol could be taking too many medications and asked me to help. Carol agreed to send me her current list of allergies, medical conditions, and medicines. Over the past several months, Carol had complained that she “felt too tired” to do the things she’d always used to have fun doing, and was in the hospital twice this winter for lung problems. She kept telling her friends, “It’s no fun getting old!”
But what if her fatigue is not from getting older but instead from taking too much medicine?
Over 1/3 of older adults take 5 or more prescription medicines. If you count vitamins and supplements, the number of people taking 5 or more medications doubled to 67% percent. Part of the reason older Americans take so many medicines is that as we get older, we collect more chronic ailments. The most common treatment doctors use for most medical conditions is medication.
Taking too much medication actually has a name: polypharmacy.
What is polypharmacy? “Poly” means “much” or “many,” so polypharmacy literally means “many medicines.”
Polypharmacy is not defined by a particular number of medicines you take, but by whether you take more medications than medically necessary.
Polypharmacy is dangerous because the more medicines we take, the more they can interact with each other and cause harmful side effects, ranging from fatigue to confusion to an increased risk of falls.
Who is at risk for polypharmacy?
Older adults like Carol, who live in their own homes are more likely to be at risk of taking multiple medicines for the same thing, or new medicines to treat the side effects of their current medication. Polypharmacy is even morel ikely if, like Carol, they see specialists or have been recently hospitalized.
How does polypharmacy happen?
When people visit a physician, they expect something to happen, and they are not often disappointed. Between 50-75% of emergency department (ED) and clinic visits result in the doctor prescribing a new medicine for you. Doctors feel pressure to provide some kind of tangible “care,” and medications are the most common form of medical treatment in the United States.
One preventable problem is that sometimes new prescriptions aren’t treating an original condition. Instead, they are prescribed to address a side effect of one of the medicines you are already taking! There’s a name for this: The Prescribing Cascade.
Several factors create conditions for polypharmacy and the Prescribing Cascade to happen. One BIG risk factor is your doctor not having complete information on the medicines you are already taking or have already tried.
Another risk factor is seeing multiple doctors, including specialists who only treat you for one specific issue. They don’t see the entire picture and may not be aware of what your other doctors have already prescribed.
Admission to a hospital for a new or worsening medical condition is another reason people end up on too many medicines. Doctors often add medications during a hospital stay, which may not be necessary once a patient’s condition stabilizes. Too often, these medicines are continued after a loved one is discharged back home.
One of the most dangerous polypharmacy situations is taking two medicines for the same thing. When you get new prescription medicine, does your doctor explain whether you ADD it to the ones you take or REPLACE an older medication with the new one? If it replaces a current drug, which one are you supposed to stop?
Using a mail-order pharmacy can also contribute to polypharmacy and the Prescribing Cascade. Mail-order medications can take a week or more until they arrive. Will you still remember what the doctor told you about your new prescription? Are you suppose to stop one of your medications when you start the new one?
Using more than one pharmacy hampers the ability of a pharmacist to recognize unnecessary or dangerous combinations of medicines because you don’t get all of your prescriptions in one place.
Why does polypharmacy tend to continue?
Power and status.
Physicians can be reluctant to change another doctor’s orders, especially if a medication is from a specialist.
A fragmented medical care system.
New and relevant information about you from specialists isn’t always shared with your other doctors promptly, creating gaps in knowledge of what has already happened to you. When vital information is missing, your doctor can prescribe medicines that you have already tried and failed or are allergic to.
Fear.
Some patients become anxious about stopping a medicine that they were told by a doctor that they would be on “for life.” They may feel that when a clinician suggests they reduce or stop that medication, they are “giving up” on them.
Do certain medicines cause more trouble than others?
Unfortunately, yes. Some medicines cause more side effects in older adults.
As we age, we gradually lose our ability to tolerate certain drugs. Adults over 65 years old are far more likely to experience dizziness, fatigue, and confusion from medication than younger people.
To avoid the Prescribing Cascade, ANY new symptom you experience should be considered a possible side effect of medicine until proven otherwise.
Here are 6 Ways to Protect Yourself from Polypharmacy and the Prescribing Cascade:
- Watch out when starting or changing medications.
After starting a new medication or after a dose adjustment, report any problems to your doctor right away. It’s better to decrease or change that medicine than end up on an additional one treating its side effects!
- Keep a complete list of ALL your medications and supplements.
Include all the non-prescription medicines and supplements you currently take, and any allergies or adverse experiences you have had with any specific drug in the past.
- Take your medication list to EVERY medical visit.
Whenever and wherever you receive medical care, give your medication list to your regular doctor, the Emergency Department, any specialist, even your dentist, and chiropractor.
- Keep your medication list updated.
After any hospital stay or appointment with a specialist, update your medication list with any new or discontinued medicines. Ask for a summary of the hospital stay or specialist appointment that includes any new plans or drugs, and use that to update your current list.
- Clarify any new medicine as either an addition OR a replacement.
Whenever you receive a new prescription medicine, make sure you understand whether it is in ADDITION to what you already are taking or REPLACES one of your current medications, along with which medicine to stop.
- Ask your pharmacist.
If you have questions about whether medicines belong together or could be a duplication, your pharmacist is a great resource.
