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Join us for a discussion on medication awareness and prescribing cascades with Paula Rochon, a geriatrician. As we embark on a new year, many focus on diet and exercise resolutions, but overlooking medication management can have profound implications for health. With nearly 4 in 10 adults over 65 taking five or more medications, polypharmacy is a pressing concern. In this episode, Paula shares insights into the risks of polypharmacy, particularly for older adults, and illuminates the phenomenon of prescribing cascades. Learn how recognizing and addressing prescribing cascades can mitigate unnecessary medication use and improve patient outcomes.

Paula Rochon is a geriatrician.

She discusses the KevinMD article, “Now is a good time to reassess your medications with your clinician.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Paula Rochon. She’s a geriatrician, and today we’re going to talk about the KevinMD article that she co-wrote. It’s titled “Now is a good time to reassess your medications with your clinician.” Paula, welcome back to the show.

Paula Rochon: Thank you, it’s lovely to be here.

Kevin Pho: So Paula’s been on in the past. Go to KevinMD.com/podcast where you can search for her name and hear her story. But today let’s jump right into this article that you co-wrote with Jerry Gurwitz and Lisa McCarthy. It’s titled “Now is a good time to reassess your medications with your clinician.” So tell us what this article is about.

Paula Rochon: Well, I think this article is something that’s really important for people to think about all the time, but we wrote it just at the start of the new year, because we were trying to get people to think about the importance of reassessing your medications. As you start out into the new year, that’s maybe something you ought to be doing.

Kevin Pho: When we come to medications, I see a lot of patients with sometimes five, 10, even 15 different medications. Talk to us about some of the dangers that you see with patients having so many medications that they’re taking.

Paula Rochon: Well, this is an issue. I’m a geriatrician, I’ve spent a long time looking after people who are older, especially women, and I see that people often use a lot of medications. You can imagine that as people get older they develop more chronic conditions, they have a need for medication, so you can understand why they’re using medications. But our concern is to think about when there are other things you ought to consider, or maybe the medications aren’t necessarily always needed, and thinking about the importance of reassessing the medications.

And so one of the pieces that we’ve talked about in this article is something that maybe people don’t think about enough, which is called prescribing cascades. That’s basically the idea that a person develops some sort of a problem, a medication is prescribed to treat that problem, and a new problem develops that’s really an adverse drug event, but it’s misinterpreted as being a new medical condition. And then people are started on another drug therapy to treat that medical condition.

And as you can imagine, that’s something that goes on and on, and it’s important because it can contribute to the development of polypharmacy, or the accumulation of further medications.

Kevin Pho: So in your clinic, give us a hypothetical, or it could be even a real case study, where you see that prescribing cascade in action.

Paula Rochon: So this is something that I started to see a fair bit in my clinical practice, and so I’ll give you some examples of how that might come forward.

As an example, a person might present with a problem with their knee. They may have knee pain, it’s something that’s not uncommon, and they may get prescribed something like an NSAID to treat that pain. And then over time, often it’s weeks or months later, perhaps they’re coming for a routine visit at their primary care provider, and it’s noticed that their blood pressure is increased. And so then it’s thought, oh my goodness, now you have a blood pressure problem and we need to treat your blood pressure.

But what isn’t always recognized is that, for example, a drug like an NSAID can over time potentially elevate your blood pressure somewhat, and that can lead to the misinterpretation that you have a new medical condition that needs to be treated. And so as a result of that, you may see somebody who’s been put on blood pressure medication when maybe they didn’t really need it.

Maybe it was about thinking about, was that initial drug therapy really needed in the first place? The person was coming in for pain in their knee, but would something like physiotherapy have been effective? Or if they needed that drug, would a lower dose have been effective? Or could they have used a different therapy, maybe something that had a lesser side effect profile, and as a result of that you wouldn’t have developed the high blood pressure and the subsequent problems? So that’s an example of a prescribing cascade, because you could do things perhaps differently.

And I remember seeing quite a number of things like that that came up over time, especially when I was working in the long-term care environment, where you were able to see people over time and you could start to reflect and see things developing.

I remember at one time, as a geriatrician we would often be called on to do consults, and we were asked to do a pre-op consult for a person who had quite profound bradycardia, quite a low heart rate, and was going to go for a pacemaker insertion. And as geriatricians, working with our trainees reviewing the case, we of course looked at the medications and noticed that the individual was on a cholinesterase inhibitor. And we noticed they’d been on that in the past, and if you looked at the records, when they were on a cholinesterase inhibitor their heart rate had slowed down, and they might have gone off and it was back up, and they were back on.

And so we realized that the low heart rate, the drug that they were on, the cholinesterase inhibitor, was contributing to that. And so by pointing that out, people were able to think, did they need that same dose of the cholinesterase inhibitor? If not, could it have been decreased? Or was it as effective as they wanted? And did that person really need to continue on that drug? And by cutting back on the drug, the heart rate came back up, and the person no longer needed to have a pacemaker inserted.

So you can see lots of stories like that started to come up in clinical practice that made you aware of more and more of these kinds of issues.

When we first talked about this, it was probably decades ago, and myself and Jerry Gurwitz wrote about this concept at that time, and a framework for thinking about it, I think first in The Lancet and then in the BMJ. And at that time we were thinking about three examples we were able to find of what we thought were prescribing cascades. But over time it’s really interesting to think that now there are over 160, some people say way more than that, of these cascades that have been identified in clinical practice. So it’s something that, if you think about it and you’re asking the questions, you may actually see them. Otherwise they go unnoticed.

Kevin Pho: Now, as you evaluate these cascades as a geriatrician, are there patterns that are common? Is there one particular scenario, one particular prescribing cascade, that comes to mind as among the most common, so us primary care doctors listening to you would be on the lookout for it?

Paula Rochon: Well, one of the things that we’ve written about a fair bit is when you’re looking at the use of calcium channel blockers. I mean, they’re a very well recognized therapy, and they’re often used for the management of high blood pressure, and that’s all very appropriate.

But one of the things that can happen is that people can develop edema, they can develop some swelling. And the interesting thing is that, when you’re thinking about this being potentially an adverse effect associated with the calcium channel blocker, it’s something that doesn’t necessarily happen immediately. It can happen over weeks or months, or a much longer time period, before it’s actually recognized. So it’s not really thought of as being associated with the drug.

But this is an important one, because often people will treat it with a diuretic, and that’s not really probably the most effective way to manage that kind of edema. But if you think that it’s related to the calcium channel blocker, then you might think about, is there a different calcium channel blocker you might use? Or again, could you decrease the dose? Or if the edema is relatively minor, can you manage it with just some of the non-pharmacologic therapies, like maybe elevating feet, or doing a few things like that that might be effective and avoid the problems of putting somebody on an additional drug therapy, which then comes with its own potential risks associated with it?

So that’s an example of one that might come to mind, and it comes to mind too because, as I say, these drugs are widely prescribed, and so it’s something that people might see in clinical practice.

Kevin Pho: Yeah, I think that really resonates with me in particular, because I’ve seen so many cases where patients were on amlodipine, for instance, a calcium channel blocker, and present with worsening edema, and either decreasing the dose of the amlodipine or coming off it completely would really help solve that issue.

Paula Rochon: Yeah, and that’s the kind of thing that we want people to really think about. But the thing about the prescribing cascades is that they’re not just like other kinds of what you might call drug adverse events. If you gave a person an antibiotic and they developed a rash, right away you say, hey, this is related to the drug.

But I think prescribing cascades get missed because that time frame can be weeks or months. It might be one physician prescribing the drug, another person evaluating it later on, and they don’t really know the pattern or the history that’s developed there. And often the kinds of things we see, like swelling for example, you may pass that off as being something that may not be uncommon to see, and so it doesn’t necessarily get the attention that it deserves.

So there are a lot of reasons why these get missed, and then that contributes to the accumulation of drug therapies, polypharmacy, and perhaps things that people don’t need to be on.

Kevin Pho: Now, as a geriatrician, and for all primary care clinicians in general, where do you start untangling potential prescribing cascades? In the United States, and I’m sure in Canada as well, we have patients going to sometimes five, six, seven specialists, where they each deal with their own siloed issue and prescribe patients medicines only within their field. And sometimes it falls to the job of the primary care physician to identify potential prescribing cascades and really just untangle all the medications that a patient comes to you with. And like you said, it could be sometimes 15 to 20 different medications. So how do you start to try to untangle potential interactions, and really see whether some of the patient’s symptoms are in fact due to polypharmacy?

Paula Rochon: Well, I think there are a couple of things that you can do, especially when you’re thinking about prescribing cascades, because I think what you said is correct. There are a lot of different physicians involved, it’s really hard to figure these things out, especially when people are on a lot of medications.

But one of the things that I find would help, it’s really helpful to have a list of medications. And I know that often, as a primary care provider, you would have a list of medications, but I think it’s also helpful for the patients to have a list of medications as well. And in there, it’s important to know when the medications were started, so that you can start to see a sequence of events which otherwise gets missed.

For example, in the calcium channel example, the calcium channel blocker was started, and then subsequent to that you see the diuretic being started. You want to see the time frame, and then you want to know who started it and why they potentially started it, so you have some of the key information to see sequences of events that might lead to the development of something like a prescribing cascade that otherwise gets missed. So I think that’s one bit that really gets missed. I think even with some of the lists that physicians have, they don’t necessarily think about the temporal relationships, and that helps to solve some of those issues.

And then it’s also really important, when you’re reviewing medications, and that should be done on a fairly regular basis, to think about what are the questions you should ask. And I think this is always important. Is that initial drug therapy required, or is it still required? Or could there be non-pharmacologic approaches that you might want to consider, like, has physiotherapy got a role, is there something else you could do to manage the problem?

And if you decide that the drug is required, is there the option of reducing the dose? Or, as you mentioned just a minute ago, could you take another drug within that class that might have a lesser side effect profile, that might deal with the problem that you were having? And is it just about a dose, could you lower the dose? Sometimes you can get a huge benefit by just doing that. And then of course it begs the question of, does that person need that medication at all? And in some cases perhaps they really didn’t need the medication.

So I know this is a bit of a process, but I think it’s important that we take the time to go through this with the patients, and to continually reassess the medications.

Kevin Pho: We’re talking to Paula Rochon. She’s a geriatrician, and today’s KevinMD article is “Now is a good time to reassess your medications with your clinician.” Paula, let’s end with some of your take-home messages to the KevinMD audience.

Paula Rochon: Well, thank you so much for having me with you today. I guess one of my big take-home messages is that it is really important to think about reassessing your medications.

We understand that medications are often very important for people and they’re needed, and that’s something that we need to make sure, that people get the right medications. But often they’re perhaps on medications that are not maybe the best for them, and it’s important to review those medications and to determine if that drug therapy, in the way it’s currently prescribed, is still needed, or whether there’s a better option that we might want to think about.

Kevin Pho: Paula, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Paula Rochon: Thank you so much for having me.