Podcast: Prescribing cascades
Transcript
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Kirsten Patrick: A phenomenon of inappropriate prescribing that often occurs in the treatment of older adults, called a prescribing cascade, is important for physicians to be aware of, although it's not always easy to detect. I'm Dr. Kirsten Patrick, executive editor for the Canadian Medical Association Journal. Today I'm talking to Dr. Paula Rochon, who is one of the authors of the CMAJ practice article called "Five things to know about prescribing cascades in older adults". Paula is a geriatrician at Women's College Hospital and the RTO chair in geriatric medicine at the University of Toronto. I've reached her today in Toronto. Hello, Paula.
Paula Rochon: Hello, how are you?
Kirsten Patrick: I'm great. Thanks for joining me today. This is a really interesting problem. So can you start by telling us what is a prescribing cascade, exactly?
Paula Rochon: Well, a prescribing cascade is something that I first saw in clinical practice when I was working as a geriatrician in the long term care setting. And it occurs when a drug therapy is prescribed when a side effect later develops, and as a result of that, the provider prescribes additional medications to treat that side effects without realizing that it's related to an earlier medication. And this in turn puts the individual at risk for further drug related problems and complications.
Kirsten Patrick: What are some noteworthy examples that you have seen perhaps in clinic?
Paula Rochon: Well, I've seen a number of them. And I think when I go back to when I, when I first started recognizing this problem, I remember, again, in the long term care setting, being asked to see an older woman who had at that time had what was recurrent and very painful gout. You know, and as you can imagine, that's not a pleasant sort of thing to have. And after going through her medications, it looked like perhaps this gout was being triggered by this, a diuretic therapy that she was being given to treat some very mild leg edema, you know, so she had a bit of swelling, and her physician would have started her on a diuretic to treat that swelling. And by figuring this out, and I must say, it wasn't something that I figured out immediately, it took a while before we sort of saw this pattern, we realized that this was really a prescribing cascade, and when we were able to recognize it, we were able to stop the diuretic, and we were able to prevent the further episodes of gout developing. And you know, we were able to find other ways to treat the edema that she had, that didn't involve a medication. So it's kind of interesting, because the fact that this person was in long term care, meant that it was somebody that we were able to see over time and to be able to see this develop. But it did bring to my attention the fact that the sequence is often not recognize because it's something that develops in weeks and months. And people might often say oh in an older person, perhaps you know, a little bit of swelling might not be unusual. So they may think it's age related and just dismiss it. And it's also not really recognized as something that would necessarily be drug related. So people don't really make the connection. But I guess, you know, when you would see people over time, and you had a chance to look for patterns, that's where things like this became apparent.
Kirsten Patrick: So I'm curious, you said it took a little while to figure it out. And it seems to me like you need to be a bit of a detective. So how did you manage to figure it out?
Paula Rochon: Well, in this particular case, I think I saw that individual more than once, you know, I must say, before I was able to identify that sequence. But it made you realize that it's really important to always look at medications, which is you know, something I think, especially people working with older people know, it's really important to look at medications. And it's important to look at the sequence of things in terms of the way they're prescribed. Because that gives you a clue, you know, what were you on first and what happened? What did you get put on next, to be able to help understand that. And in fact, it was a very interesting paper that was led by Katrina Piggott, who talked about using process maps to help identify this sort of thing. So you're able to basically illustrate and draw little sketches and figures about sequences of events to see how these patterns might emerge. Because I think, you know, unless you think about it, and sort of asked specifically about it and look for sequences, events, it's very easily missed.
Kirsten Patrick: And are prescribing cascades very common? Do we know how common they are?
Paula Rochon: So I think prescribing cascades are really common. When we first started looking at this, I think we identified about three different prescribing cascades. And that's what got us thinking about it. But it's a pattern that you see so often, if you really look for it. And when we wrote about it, a couple of years ago, I think we identified over 20 different prescribing cascades. As new therapies come on the market, they'll continue to be identified, because it's sort of, it's a pattern that keeps repeating itself. We've also, when we've looked at prescribing cascades, we initially were looking at a drug leading to a side effect that was missed. And then as a result of that new medical condition and another drug prescribed, we've also realized that it also relates to drugs that are being given or taken over the counter. So it's not just a prescribed medicine. So there's many of these that, you know, as a physician, you may not see unless you really ask about what other kinds of medications an individual has taken. And it can also lead to the use of a medical device. So you know, the piece that we've talked about is one component of the prescribing cascade. And there's many such prescribing cascades, but there's other pieces to it as well that I think are important.
Kirsten Patrick: So let's just stick with drugs. Can you talk about whether prescribing cascades contribute to polypharmacy in older adults?
Paula Rochon: I think they are a big component of polypharmacy. And in fact, when you think about polypharmacy, one of the definitions of polypharmacy is something called problematic polypharmacy. And that's when drugs are used, multiple drugs are used in a way that isn't really appropriate and isn't providing benefit. And when you look at the components of problematic polypharmacy, one of the components is when a medication is being prescribed as part of a prescribing cascade. So not only does that lead to polypharmacy, but it's part of the definition of problematic polypharmacy. And of course, you know, polypharmacy is such a big issue for older people, especially women. And so by thinking about the prescribing cascade, that's one way to focus attention on drug therapies that could potentially be stopped, and therefore could reduce the problem of polypharmacy.
Kirsten Patrick: So I wonder if, you've given us one example from your own clinical practice, but what's kind of a really, really common prescribing cascade that leads to polypharmacy? What sort of chain of events might we see in a hypothetical situation?
Paula Rochon: Well, one of the ones that I think is a pretty common one is if you can imagine, you know, somebody comes in with some sort of arthritis, and they're having problems, you know, say with their knee, and they may get prescribed non-steroidal anti-inflammatory type drugs, you know, that's something that would happen, or could happen fairly commonly amongst older people in particular. And what may happen in that scenario is, you may see an elevation of blood pressure that may happen over time, these things don't usually happen immediately, it's over weeks and months that this might be noted, and an older person coming in with an elevated blood pressure, you know, again, that might not be thought of as being unusual that people may think that it could be associated in part with age, and therefore would put them on an antihypertensive medicine. And that, of course, could put people at risk for further problems that may cause potential harm. So that's an example of a non-steroidal anti-inflammatory drug, leading to hypertension, and therefore, the initiation of an anti-hypertensive. I think it's an example, that is one of the common ones. And you can imagine that that could be the result of a prescribed medication or it could potentially be something taken over the counter.
Kirsten Patrick: Yeah, I imagine that is very common. So what's the best way for physicians to prevent prescribing cascades in the first place?
Paula Rochon: Well, I think when you're thinking about prescribing, you know, I think you always need to think about you know, when you're starting the drug, is this drug needed at all. So if you're thinking about somebody showing up, for example, with something like arthritis discomfort, is it possible that you could think about a non-pharmacologic approach. So that would be an obvious sort of place that you might want to start. But if you are thinking about starting a drug therapy, you obviously want to pick something that has the fewest potential side effects associated with it, and using the lowest dose that you potentially need to do. So that's sort of one of the things that you might be doing going forward. But if you're thinking about the the prescribing cascade, and when you're looking at a person who's in front of you, and you're thinking about their medications, I think it's important to sort of stop and always sort of look at the medications. And, you know, wonder if these potentially could be leading to a prescribing cascade. And if they are, the way you might identify it is by understanding the sequence of events that has developed in terms of how that came to be. And then you'd have to ask, you know, take a look at the initial medication, like, for example, in this case, the NSAID. And you might ask, you know, first off, do they need that medicine? Is it something that they need at all? Could there be a non-pharmacologic approach? Could the dose be lowered? Or is there another therapy that could be used instead, that wouldn't result in such a prescribing cascade. So I think it's important that people think about whether they might potentially be causing a prescribing cascade in terms of meds, they might be thinking about prescribing, or also looking to identify ones that may already exist, and therefore what they might need to do to potentially reverse that process.
Kirsten Patrick: I find that interesting. And just to share a little thing of my own is, I'm in my late 40s, I take ibuprofen on the regular for chronic arthritis, I told my family physician about this, and she said to me, but you need to bear in mind that if you take those drugs, they put you at risk of hypertension. So I wondered if it's prudent to talk to patients, and even caregivers of older adults, and educate them to be aware of this phenomenon, something that they might need to think about in the future.
Paula Rochon: I think that's a very important piece that we must think about doing. I think it's very important to involve patients and where they're involved caregivers in that whole process. So making people aware of what some of the potential issues might be related to the drug therapy. So if that were to occur, they would know perhaps, what it might be related to and allow them to ask questions about their medicines. So I think that is a really important thing that you want people to do. It's also, I think, one of the things that strikes me is often it's difficult for people to remember, for example, why their drugs were prescribed and when they were prescribed. And so if you knew that information, you could often understand, you know, perhaps the sequence of events, what you were prescribed first, and then what happened next, which would make it easy to start to see some of these problems emerge. And I think that relates to the way we prescribe and very helpful for patients, for example, to have the list of their medications to have the dates when they were started. And to have an understanding of the kind of benefit that they expect to get from those medications, but also some of the common side effects, so they're aware of these things.
Kirsten Patrick: I always wonder how easy it is for people who are on a fair number of medications to keep track of them and when they were started. So I'm thinking about somebody who was admitted to hospital and a medication was started on discharge, or started by a specialist that the family doctors know about, and how feasible it is for them to keep track of which doctor prescribes which medication but probably useful for them to do that, right?
Paula Rochon: Yeah, I hear what you're saying. And we obviously have systems to do this. We have electronic systems that we can use, and we should use for this purpose as well. But I do think it's helpful for patients to have that information wherever it is feasible, because, you know, they're often the ones that know a lot of this background information, you know, why it was started and when and the circumstances and so I think it is really important for them to see that. And also, when we think about prescribing cascades, they often happen, you know, in my view, when care becomes a little bit fragmented, shall we say? So for example, one of the ones that we talked about a lot or early on, we wrote about, that I thought was important, was the use of cholinesterase inhibitor medications for the management of, for dementia. And one of the complications related to that is that people often developed urinary incontinence, but it would happen, you know, down the road, you know, months down the road. But what might happen is an individual would be referred to a urologist to have that evaluated. And so they were sort of, you know, somewhat outside of the of the initial decisions around the therapies. And they may go on and suggest investigations and further drug treatment without it necessarily going back and tying back necessarily to the medications. And so it's important, that sort of, this sequence of events is always brought back and brought to people's attention. Because I think these prescribing cascades are more likely to happen, when it's different settings involved, settings of care, and different prescribers also involved in the process. So it is complicated. But I think there are things that we can do to help prevent them and when they're identified to make sure that where it makes sense that they're reversed.
Kirsten Patrick: Now, if a physician has done their detective work, and they've identified a prescribing cascade in a patient, determining that the symptoms are in fact an adverse reaction to a prescribed drug, what's the next thing they should do?
Paula Rochon: Well, I think that the first step is I think they need to recognize it. And they need to decide what the appropriate approach might be. So in some cases, it may make sense that they recognize it, but it's something that they decide that they need to continue with. In other cases, it may be that they can take other options to sort of minimize the side effects. So for example, if we're looking at the one I just mentioned about cholinesterase inhibitors leading to incontinence, you know, the decision might be around the use of the cholinesterase inhibitors, you know, did it provide benefit, and if it was providing benefit, then maybe the decision would be that, therefore, we will treat the incontinence and that's going to be how we're going to focus our management, but if it wasn't providing the benefit that you wanted, then people may go back and question the need for the original drug. So I think physicians have to take the information, and then customize it to what the best approach and answer is for that individual. So in the case that you mentioned earlier around the idea of an NSAID being used to treat some, let's just say some knee discomfort, you know, you could look at that, and if a person was on an NSAID for this knee discomfort, ended up getting some hypertension, were put on an antihypertensive, and you look at that scenario, and you said, goodness, that knee discomfort could be managed with the non-pharmacologic approach, you know, maybe it was exercise or something like that, and I don't need this drug. Then you're able to stop the medicine for the hypertension and stop the NSAID and take away those additional risks and that would be of great benefit to the person. And another scenario, maybe it means if you feel that they do need some of that medication, maybe they could just reduce the dose, and that may minimize the impact in terms of hypertension, or in some cases, maybe the discomfort could be managed with a different sort of medication, like perhaps acetaminophen could be adequate. So people have to kind of customize their response to the individual, there's not always a single right answer. But the important thing is, I think people need to recognize it, because in many cases, it can mean that doses are reduced, or drugs are stopped. And then that not only takes away the need for possibly two medications, but in some cases, this cascade has gone further than just that. And there's been other medications involved as well. So I think it's really important to think about that. And then to figure out obviously, how you can minimize that impact.
Kirsten Patrick: These articles, Five Things to Know, in practice are really handy tips for practicing doctors to keep up to date. And often the people who write them have a particular agenda – we want people to know about this condition, or we want them to know these particular things about it. So what do you want physicians to remember about prescribing cascades that led you to write this article?
Paula Rochon: I think we want physicians to think about it. And so success, I think, is that when you have a patient that you're seeing who maybe presents with the problem, you know, maybe it's somebody showing up with with hypertension, you might be asking, could it be related to that NSAID that they're on and you need to be starting to think about whether the medications that the person is on could be contributing to this prescribing cascade kind of process because you really want physicians to sort of ask those questions so that they can relook at the medicines that people are on and make sure that people are only on the medicines that they need to be on. And that's such an important strategy for reducing polypharmacy, as we've talked about, but also the risks associated with polypharmacy. And it's particularly important for older people and women who are likely to be on more medications.
Kirsten Patrick: Paula, thank you for joining me today to talk about this short practice article and expand on what you've written in your one pager. It's been great to talk to you.
Paula Rochon: Well, thank you very much, and thank you for the invitation.
Kirsten Patrick: Thanks, Paula. I've been speaking with Toronto geriatrician, Dr. Paula Rochon. To read the article she co authored, visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Kirsten Patrick, executive editor for CMAJ. Thank you for listening.