An examination of three prescribing cascades in a cohort of older adults with dementia

Abstract

Background Prescribing cascades are a source of inappropriate prescribing for older adults with dementia. We aimed to study three prescribing cascades in older Nova Scotians with dementia using administrative databases. Methods Cohort entry for Nova Scotia Seniors’ Pharmacare Program beneficiaries was the date of dementia diagnosis. Prescription drug dispensing data was extracted for inciting medication and second treatment (cholinesterase inhibitor and bladder anticholinergic, metoclopramide and Parkinson’s disease medication, or calcium channel blocker (CCB) and diuretic) over the six-year period April 1, 2009 to March 31, 2015. In three separate analyses, dispensing an inciting medication signaled a look back of 365 days from the date of first dispensing to confirm that the second treatment was started after the inciting medication. The prescribing cascade was considered when the second treatment was started within 180 days of the inciting treatment. Sex differences in the prescribing cascade were tested using t-tests or chi square tests as appropriate. Both univariate (unadjusted) and multivariate (adjusted) logistic regression (adjusted for age, rurality, and sex) and Cox proportional hazards regression was used to identify risk factors for the prescribing cascade. Results From March 1, 2005 to March 31, 2015, 28,953 Nova Scotia Seniors' Pharmacare beneficiaries with dementia (NSSPBD) were identified. There were 60 cases of bladder anticholinergics following cholinesterase inhibitors, 11 cases of Parkinson’s disease medication following metoclopramide, and 289 cases of a diuretic following CCB in the cohort. Regression analysis demonstrated that risk of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were associated with female sex. Cox regression suggested that bladder anticholinergics were less often used by those on cholinesterase inhibitors and did not identify CCB use as leading more frequently to diuretic use. Conclusions The combination of diuretics following CCB was the most common prescribing cascade and bladder anticholinergics following cholinesterase inhibitors the second most common. However, exposure to the inciting medications did not increase risk of exposure to the second treatments. Combinations of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were more common for women raising concern that women may be at increased risk of these prescribing cascades.

Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review

“…Therefore, bladder anticholinergic agents such as oxybutynin, tolterodine, trospium and solifenacin are usually used to relieve urge incontinence which called AChEI-induced urinary incontinence prescribing cascade. 177 prescribing cascade is AChEI-induced rhinorrhea which is concomitant use of rhinorrhea medications to relieve side effects of AChEIs. The rhinorrhea medications consist of antihistamine, nasal anticholinergics and nasal glucocorticoids.…”

Prescribing cascades in community-dwelling adults: a systematic review

“…]65 years) were more likely to receive; i) anticholinergics for urinary incontinence following SSRI initiation, 41 ii) ulcer drug therapy within 100 days of NSAID initiation, 91 iii) diuretic to treat betablocker induced oedema, 36 and, iv) thyroxine for hypothyroidism following amiodarone initiation. 87 Females were more likely to receive an antitussive for cough following ACEI initiation, 74 anticholinergic medication for urinary incontinence following acetylcholinesterase inhibitor 24,30 and SSRI initiation, 41 and levothyroxine following amiodarone initiation. 87 Differential associations were identified for initial medication dosage in nine studies.…”

“…Several studies reported stratified results by dosage, 5,7,28,29,39 concomitant medication use or polypharmacy, 7,40,44,87,106 duration, 32,96 comorbidity, 36,38,40,44 race 34 and nursing home residence. 26 For other studies, analyses were adjusted by age, 20,22,30,52,71,91,121 sex, 20,22,30,52,71,74,84,121 race, 22,121 dose, 52,71 nursing home residence, 22 concomitant medication or polypharmacy, 22,52,71 comorbidity, 121 with some studies conducting adjusted analyses but not reporting the independent association of these covariates. 23,27,31,90,119,120 Length of follow up ranged from one month 55,93,109,…”

“Kind of blurry”: Deciphering clues to prevent, investigate and manage prescribing cascades

“…Many prescribing cascades have been identified and their potential impact on patients described [3][4][5][6][7][8][9]. Much of the existing research on prescribing cascades has used healthcare administrative data to assess their prevalence and impact [10][11][12][13][14][15][16]. Resources have been identified that can help people prevent, detect and reverse prescribing cascades but there remain outstanding knowledge gaps regarding both clinicians and patients' experiences with identifying and addressing them as well as how and why prescribing cascades occur in practice [9,17,18].…”