New study reveals prescribing cascades increase after entering aged care

New research has uncovered widespread and potentially harmful patterns of medication prescribing among older people entering residential aged care, prompting calls for earlier intervention and routine medication reviews during one of the most vulnerable periods in the care journey.

The study, published in Age and Ageing, analysed the medication records of more than 167,000 Australians aged 65 and over who moved into long‑term care facilities. Researchers from the Registry of Senior Australians (ROSA) at the South Australian Health and Medical Research Institute (SAHMRI) and Flinders University found that 16.7 per cent of residents experienced at least one prescribing cascade before entering care, a figure that jumped to 25.1 per cent after admission.

Prescribing cascades occur when a side effect of a medication is mistaken for a new medical condition, leading to the prescription of an additional drug. Over time, this can compound medication burden, increase the risk of further side effects and heighten the likelihood of falls, hospitalisation and other medication‑related harms.

“Transitioning into residential aged care is one of the most vulnerable periods for older people when it comes to medication safety,” lead researcher Professor Gill Caughey said.

“What we’re seeing is that many residents are exposed to patterns of prescribing that may unintentionally lead to harm.”

The study identified 61 unique prescribing cascades, many involving medicines already considered high‑risk for older people, including antipsychotics, benzodiazepines and opioids. Researchers say the findings highlight a significant but under‑recognised safety issue in aged care.

Risks increase after entering aged care

The research found prescribing cascades were more common after residents entered aged care, a period marked by changes to medication regimens, increased frailty and more complex health needs. More than half of the cascades occurred within 30 days of starting a new medication, suggesting many were responses to acute side effects.

“While in some instances prescribing may be appropriate, however we found many prescribing cascades that involved medications deemed inappropriate by international guidelines for the older population,” Professor Caughey said.

The study also identified additional cascades among people living with dementia, often linked to sleep disturbance, agitation and sedation. These cascades frequently involved psychotropic medicines, which carry heightened risks for people with cognitive impairment.

“For people living with dementia, the risks can be even more complex,” Professor Caughey said.

More than half of the cascades involved medications listed in the Beers Criteria, an international guideline identifying drugs that may be inappropriate for older adults. These included benzodiazepines, antipsychotics, proton pump inhibitors, diuretics and sedatives.

The study also found stronger associations between certain medication combinations after aged care entry, including:

• beta‑blockers or statins followed by antidepressants
• calcium channel blockers followed by diuretics
• benzodiazepines followed by antipsychotics, with incident use doubling after entry into care.

Researchers say these patterns reflect both the complexity of older residents’ health needs and the challenges clinicians face in distinguishing new symptoms from medication side effects.

Call for routine medication reviews and deprescribing

The authors argue that the findings highlight a clear opportunity to improve medication safety through earlier intervention, particularly at key transition points such as entering aged care.

“There’s a real opportunity here to intervene earlier through routine medication reviews, better monitoring of side effects and, where appropriate, deprescribing strategies,” Professor Caughey said.

“Improving awareness of prescribing cascades among clinicians and care teams can help ensure we’re treating the root cause of symptoms, rather than unintentionally adding to the burden of care and placing older people at increased risk of harm.”

The study is the first in Australia to comprehensively examine prescribing cascades before and after entry into long‑term care, and researchers say the findings should inform national efforts to strengthen medication safety in aged care.