Caring for older people with multimorbidity and polypharmacy is now the greatest challenge faced by health systems internationally. Polypharmacy becomes inappropriate when medication risks begin to outweigh benefits for patients and can lead to serious adverse drug events (ADEs). Research has characterised potentially inappropriate prescribing (PIP) using explicit prescribing indicators, such as the US Beers criteria and the European STOPP/START criteria. Very little is known about other potential causes such as prescribing cascades. A prescribing cascade can occur when a medication is prescribed that causes an ADE that is then misinterpreted as a new medical condition resulting in the prescription of another medication. ADEs can be difficult to recognize as they often present with non-specific symptoms (e.g. falls, fatigue or constipation). The overall aim of this project is to characterize problematic polypharmacy in older community-dwelling adults, with a particular focus on prescribing cascades.
Work package one: Developing a prescribing cascade indicator set
To conduct a systematic review to identify examples of common prescribing cascades in older community-dwelling adults.
To conduct stakeholder analysis eliciting perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades.
To conduct an international Delphi consensus to develop a prescribing cascade indicator set for application to routine data.
Work package two: Applying a prescribing cascade indicator set
To examine the prevalence of this prescribing cascade indicator set in four national and international large-scale observational datasets.
To examine patient characteristics associated with prescribing cascades (e.g. age, gender, deprivation)
To examine any association between prescribing cascades and subsequent healthcare utilisation and functional decline.
Work package three: Validating and comparing prescribing indicator sets
To validate an explicit measure of PIP (STOPP version-2) and any association with healthcare utilisation and functional decline
To compare the impact of STOPP-identified PIP versus prescribing cascades on healthcare utilisation and functional decline.
