Prescribing Cascades: Back to the Future by Dr. Paula Rochon
Kali De Repentigny, MSc Candidate, Translational Medicine Graduate Program
This week’s medical ground rounds presenter, Dr. Paula Rochon, emphasized the importance of prescribing cascades, a term that she coined with Dr. Jerry Gurwitz in the nineties. The term “prescribing cascade” refers to the prescribing of medications due to the side effects of another drug being mistaken as a new condition. More recently, the concept of an expanded prescribing cascade has been highlighted, which is inclusive of devices, and other therapies than medication, such as pacemakers or physiotherapy, that are prescribed to treat side effects from medications. This results in an unoptimized drug therapy regimen for the patient, and an inappropriate use of health care and financial resources.
As a Geriatrician working at Baycrest Centre in Toronto shortly after finishing her Masters of Public Health at Harvard, Dr. Rochon noticed a commonality in the treatment of many of her patients. These individuals were prescribed cholinesterase inhibitors to treat their dementia, and eventually developed syncope which was mis-identified as a new condition and then treated. This commonality cultivated an investigatory interest in Dr. Rochon, and lead to her research ever since. She describes the long-term care facility as an ideal location for this type of research, as she can consistently observe patient changes over long periods of time. Now based out of the Women’s College Hospital, Dr. Rochon’s research focuses mainly on the various prescribing cascades seen in aging patients.
Dr. Rochon tackles the prescribing cascade issue in three separate steps: prevent, detect and reverse. Ultimately, physician awareness combined with increased patient self-advocacy could prevent prescribing cascades from ever progressing past the first medication. Not only is the medication important to consider, but so is the dose of the treatment as it can cause new symptom development if the dose is too high. A pharmacist is often responsible for the detection step, either before the next treatment is started, or after the cascade has begun. Dr. Rochon discussed several different techniques for detection of prescribing cascades, with social media mining being one of the more original concepts. Her research team has more recently taken to Twitter in order to detect some of the more frequent cascades, based off of what patients and their support team tweet to the public. She feels that privacy can easily become infringed upon with social media mining, and cautioned us against its misuse.
As chronic diseases are increasingly prevalent with aging, so is polypharmacy. It is estimated that 40% of individuals over 85 are on 10 or more medications. This concept is now a globally researched phenomena, with 13 countries addressing the issue. Australia seems to be in the forefront of prescribing cascade minimization, as deprescribing guidelines were published in 2015 and have been followed since. Several other countries have independent or joined studies on the topic, focusing on creating prescribing cascades inventories, discussing gender and cultural differences of prescribing cascades, and addressing the appropriateness of polypharmacy. With the aging population in Canada, it is important to establish a protocol to prevent and detect prescribing cascades now in order to optimize resource allocation and prepare for the influx of geriatric patients in the near future.