Prescribing cascade When a medication is prescribed in anticipation of or in response to an adverse effect caused by a medication, a prescribing cascade is initiated and can easily lead to or complicate polypharmacy (O’Mahony & Rochon, 2022). This phenomenon can be exacerbated by inadequate stewardship of a patient’s medication list (e.g., failure to conduct a thorough medication reconciliation at each medical encounter), increasing numbers
of prescribing healthcare providers, and/or a prescriber’s incomplete familiarity with a medication. While sometimes a necessary approach to appropriate patient care, as in the addition of a laxative to an opioid regimen, a prescribing cascade can often be nonproductive or even harmful, as in the case of adding an anticholinergic drug to offset extrapyramidal effects from dopaminergic medications.
TOOLS AND GUIDELINES FOR MEDICATION PRESCRIBING IN OLDER ADULTS
AGS Beers criteria Originally published in 1991 and containing 30 criteria for establishing inappropriate medication use in nursing home patients, the Beers criteria were established to improve the quality of care for older adults by reducing medication exposure to potentially inappropriate medications (PIMs) with less favorable benefit–harm risk compared to other alternative treatments (Beers et al., 1991). The criteria present a variety of approaches to improving care, including enabling better medication selection, educating clinicians and patients, reducing adverse drug events, establishing a tool to evaluate the cost and quality of care, and providing a method to characterize drug use patterns. The target audience has expanded from its initial focus on nursing home patients to now include all adults aged 65 years and older in acute, ambulatory, and institutionalized settings. Exceptions to the criteria are made for those in hospice and palliative care. The American Geriatric Society began its stewardship of the criteria in 2011 and has issued several updates at approximately three-year intervals. The most recent update, issued in April 2023, reflects new and changed recommendations since the publication of the 2019 update (2023 AGS Beers Criteria Update Expert Panel, 2023). Recommendations are presented in a series of tables, each encompassing different criteria. What is likely the most important section for many is Table 2, which lists PIMs for use in older adults. Information in this table is categorized at the highest level by organ system or therapeutic category followed by drug class (if applicable), then individual drug. For each line entry, a rationale for inclusion is provided, followed by a recommendation (e.g., avoid under certain circumstances, or consider the alternative). Additionally, an assigned level of evidence quality and strength of recommendation is provided for each line item. Similar to the 2019 version, the 2023 version of the AGS Beers Criteria encompasses five main categories of recommendations, as follows: ● Potentially inappropriate medications in most older adults: 1 addition, 13 drugs with modifications of previous criteria, and 28 medications removed from the 2019 version due to low use or removal from the U.S. market (Table 2). STOPP/START In 2008, Gallagher and colleagues proposed a set of screening tools that would guide the avoidance of inappropriate prescribing and suggest medication additions to avoid potential prescribing omissions (Gallagher et al., 2008). These two approaches befit the acronyms STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment), respectively. The original version of STOPP contained 65 criteria, and 22 indicators supported prescribing in START. Unlike the AGS Beers Criteria, which in some cases simply list mediation categories or specific medications to avoid in older adults based on adverse effects, the STOPP criteria provide more specific situations in which medication would be inappropriate. For example, tricyclic antidepressants (TCAs) are listed in Table 2 (medications to avoid) of the Beers Criteria, with the rationale of being highly anticholinergic, sedating, and prone to causing orthostatic hypotension. Among the STOPP criteria, there are six separate criteria for which TCAs are considered potentially inappropriate: Dementia, glaucoma, existing cardiac conduction abnormalities,
● Drugs that should typically be avoided in older adults with certain conditions, for example, drug–disease or drug–syndrome interaction: 10 conditions, including 3 new additions, 4 removals, and 6 clarifications from 2019 (Table 3). ● Drugs to be used with caution; some cause for concern but evidence or clinical context not yet sufficient to be a PIM: 6 recommendations encompassing a variety of specific drugs or drug classes, 2 new additions, and 3 changes from 2019 (Table 4). ● Drug–drug interactions to avoid: 12 drug/class combinations, 2 removals, 3 additions, and 4 changes from 2019 (Table 5). ● Medications that require renal dose adjustments: 24 drugs or drug classes, 1 new addition, and 2 removals from 2019 (Table 6). Additional information in the form of tables within the 2023 AGS Beers Criteria includes a list of 41 medications within eight drug classes that possess strong anticholinergic properties (Table 7). As discussed previously, elderly patients’ excessive exposure to anticholinergic medications is associated with increased fall risk. Refer to the Therapeutic Targets section of this course for additional detail regarding anticholinergic medications. As noted above, removals of medications/classes from 2023 relative to the 2019 version are summarized in Table 8. They are attributable to common use or market removal factors, not a change in the risk–benefit ratio of the affected drugs. Medications or criteria newly added and a summary of changes to the criteria since the 2019 update are itemized in Tables 9 and 10, respectively. The authors reinforced the sentiment from previous versions that the term avoid in the context of these guidelines does not explicitly mean contraindication. Unless specifically contraindicated in a medication’s labeling, these guidelines suggest that a medication or circumstance to avoid would be chosen infrequently and only after a careful risk–benefit assessment. The 2023 AGS Beers Criteria for potentially inappropriate medication use in older adults can be found here: https:// agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 constipation, concomitant opioid or calcium channel blocker use, and prostatism or a history of urinary retention. START criteria contain recommendations such as angiotensin-converting enzyme inhibitor therapy following acute myocardial infarction and regular beta-2 agonist therapy for mild to moderate asthma or chronic obstructive pulmonary disease (COPD). Dalleur and colleagues identified that 27% of hospitalizations of elderly patients were associated with inappropriate prescribing, which includes potentially inappropriate medications (PIMs) or potential prescribing omissions (PPOs), according to the original STOPP/START criteria (Dalleur et al., 2012). An update to the STOPP/START criteria, version 2, was published in 2015 (O’Mahony, et al., 2015). The expert panel reached a consensus to include 80 STOPP and 34 START criteria, a 31% increase in criteria 1, even after removing 15 version 1 criteria. Following the release of STOPP/START version 2, Thevelin and colleagues evaluated 100 of the 302 patients from the Dalleur study to compare the number of PIMs and/
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