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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 62-64

Prescribing cascade in a geropsychiatric patient: A slippery slope

1 Department of Pharmacy, University of California San Diego Health, San Diego, La Jolla, CA, USA
2 Department of Psychiatry, University of California San Diego Health, San Diego, La Jolla, CA, USA
3 School of Medicine, University of California, San Diego, La Jolla, CA, USA

Date of Web Publication27-Jun-2018

Correspondence Address:
Patricia A Pepa
200 West Arbor Drive, San Diego, CA, 92103
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_17_17

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A prescribing cascade is a situation, in which an adverse drug reaction is mistaken for a new medication condition, and a new medication is prescribed. We present a case, in which risperidone led to a prescribing cascade in a geriatric patient. We share this case to improve awareness and vigilance of prescribing cascades in the geropsychiatric population.

Keywords: Adverse drug reaction, antipsychotics, polypharmacy, prescribing cascade, risperidone

How to cite this article:
Pepa PA, Langley-DeGroot MH, Rule OS. Prescribing cascade in a geropsychiatric patient: A slippery slope. J Geriatr Ment Health 2018;5:62-4

How to cite this URL:
Pepa PA, Langley-DeGroot MH, Rule OS. Prescribing cascade in a geropsychiatric patient: A slippery slope. J Geriatr Ment Health [serial online] 2018 [cited 2022 Jul 7];5:62-4. Available from:

  Introduction Top

Prescribing cascades occur when an adverse drug reaction (ADR) is mistaken for a new medical condition and a new medication is prescribed. This can lead to a slippery slope of inappropriate prescribing and unintended harm. The geriatric population is particularly vulnerable given age-related changes in pharmacokinetics and pharmacodynamics, multiple comorbidities, and the high prevalence of polypharmacy in this population.[1] A meta-analysis reported that one in six hospital admissions of older adults is due to an ADR, which is four times the rate in younger persons.[2] ADRs may be difficult to recognize because their signs and symptoms can often have multiple etiologies. Prescribing cascades have been described in several case reports.[3],[4],[5],[6] This is the first case report, to our knowledge, involving a geropsychiatric patient and an antipsychotic, risperidone.

  Case Report Top

A 74-year-old, 41.2 kg, Caucasian woman was admitted to an inpatient geropsychiatric unit for the assessment of symptoms including worsening depression, anxiety, and frequent falls. Her medical history was notable for major depressive disorder, unspecified psychotic disorder, unspecified anxiety disorder, pseudobulbar affect, and hypertension. Her medications included aspirin 81 mg daily, dextromethorphan-quinidine 20–10 mg daily, fludrocortisone 0.3 mg daily, gabapentin 600 mg 3 times daily, memantine 10 mg twice daily, potassium chloride 10 meq daily, risperidone 0.5 mg every morning and 1 mg nightly, trazodone 50 mg nightly, and vortioxetine 20 mg daily.

She was previously hospitalized in a geropsychiatric unit 3 years prior for depression with psychotic features and possible bipolar disorder. She was started on risperidone but left the hospital against medical advice before completing a thorough psychiatric assessment. Subsequently, she was assessed by an outpatient neurologist. Rather than considering a medication side effect as an etiology of this patient's cognitive decline, she was diagnosed with a neurocognitive disorder, in spite of normal brain imaging and prescribed memantine. Memantine, known to predispose to psychotic symptoms as a result of its antagonistic activity at N-Methyl-D-aspartic acid receptors, resulted in the development of an odd affect. A third physician, in primary care, diagnosed her with pseudobulbar affect and started dextromethorphan-quinidine, a medication with strong anticholinergic properties associated with impaired cognition. She developed worsening cognition and psychotic symptoms, which resulted in her psychiatrist, increasing her risperidone dose from 0.5 mg twice daily to 0.5 mg every morning and 1 mg nightly. She experienced orthostatic hypotension and frequent falls, one of which she went to the emergency room. As a result, she was started on fludrocortisone 0.3 mg daily, which caused hypokalemia. This resulted in the addition of potassium chloride 10 meq daily. Naranjo scores for each ADR are shown in [Table 1]. The sequence of prescriptions and symptoms is shown in [Figure 1].
Table 1: Naranjo algorithm scores for each adverse drug reaction

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Figure 1: Sequence of prescribing cascade

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On the patient's most recent admission, she had a Montgomery-Asberg Depression Rating Scale (MADRS) score of 30 and a Montreal Cognitive Assessment (MoCA) score of 14. Orthostatic vital signs showed a blood pressure of 101/74 and heart rate of 80 while sitting, and blood pressure of 88/52 and heart rate of 92 while standing. Blood gases were not assessed. On admission, her complete blood count and complete metabolic panel (CMP) were within normal limits, except for hypokalemia with potassium of 2.9. No imaging studies were indicated at this time. The patient's initial urine analysis showed trace leukocytes and >100,000 g negative rods. Although she was asymptomatic, she was treated with sulfamethoxazole and trimethoprim, and subsequent urine analysis showed no sign of infection. During this admission, memantine, risperidone, and dextromethorphan-quinidine were tapered off slowly due to sedation and confusion. During this admission, no psychotic symptoms remerged after discontinuing risperidone. Her orthostatic hypotension resolved with the down-titration of risperidone. Thus, fludrocortisone and potassium chloride were discontinued and her hypokalemia resolved. The patient had a blood pressure of 134/74 without orthostatic changes, and a repeat CMP within normal limits, with a potassium of 3.9 on discharge. During this admission, her underlying etiology was assessed to be an unspecified depressive disorder, given her dysthymia, anhedonia, loss of appetite, and absence of psychotic symptoms. She responded well to five courses of electroconvulsive therapy, with her MADRS score improving from 30 to 18. Her MoCA score improved from 14 to 22 consistent with mild neurocognitive changes in the setting of depression. She was discharged in improved condition and her medication regimen was simplified.

  Discussion Top

This case highlights the importance of maintaining a high degree of suspicion for prescribing cascades in the field of geropsychiatry. Prescribing cascades have been described in several case reports.[3],[4],[5],[6] Ponte et al., recently proposed the use of an algorithm to detect prescribing cascades.[7] We urge that pharmacists and physicians work in concert to ensure that prescribing cascades are detected and ameliorated, particularly when caring for geriatric patients who are at elevated risk. Comprehensive medication reviews and early detection of ADRs can help prevent prescribing cascades.

This case also demonstrates that how incomplete transfer of information among providers in different health-care settings can exacerbate prescribing cascades. Geriatric patients are more likely to receive care from multiple providers and move between different health-care settings, and poor “handoff” has been linked to more adverse events.[8] Unfortunately, we did not have access to her outside medical records, which may have contributed to a challenging “handoff.” This case demonstrates that an interdisciplinary treatment approach is necessary for the provision of comprehensive care to the medically complex geriatric patient. In our case, it is unclear what led to the communication breakdown between providers, but physicians' attitudes toward a holistic medical approach, time constraints, and insufficient staffing are factors that may have played a role and merit further investigation.

Her outpatient neurologist and psychiatrist were not in our health-care system, and thus, we were unable to access her records. The sequence of events was primarily taken from her husband, and we utilized the Naranjo Algorithm to categorize the likelihood of her symptoms from an ADR. Based on the Naranjo scores, the symptoms were likely due to a medication given improvement in symptoms when the medications were discontinued.

The American Psychiatric Association recently developed a guideline regarding the use of antipsychotics for the treatment of agitation or psychosis in the geriatric population, which recommends low doses for a short period of time.[9] An attempt to taper and withdraw an antipsychotic drug within 4 months of initiation is recommended.[9] This case further demonstrates that how judicious prescribing of antipsychotics is warranted to prevent patient harm.

Altogether, prescribing cascades can lead to detrimental consequences and should be identified as early as possible. The authors share this as a learning case to heighten suspicion in geropsychiatric patients who present with polypharmacy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Parameswaran Nair N, Chalmers L, Peterson GM, Bereznicki BJ, Castelino RL, Bereznicki LR, et al. Hospitalization in older patients due to adverse drug reactions – The need for a prediction tool. Clin Interv Aging 2016;11:497-505.  Back to cited text no. 1
Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): A meta-analysis of observational studies. Pharm World Sci 2002;24:46-54.  Back to cited text no. 2
Liu PT, Argento VS, Skudlarska BA. Prescribing cascade in an 80-year-old Japanese immigrant. Geriatr Gerontol Int 2009;9:402-4.  Back to cited text no. 3
Nguyen PV, Spinelli C. Prescribing cascade in an elderly woman. Can Pharm J (Ott) 2016;149:122-4.  Back to cited text no. 4
Gill SS, Mamdani M, Naglie G, Streiner DL, Bronskill SE, Kopp A, et al. Aprescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med 2005;165:808-13.  Back to cited text no. 5
Caughey GE, Roughead EE, Pratt N, Shakib S, Vitry AI, Gilbert AL, et al. Increased risk of hip fracture in the elderly associated with prochlorperazine: Is a prescribing cascade contributing? Pharmacoepidemiol Drug Saf 2010;19:977-82.  Back to cited text no. 6
Ponte ML, Wachs L, Wachs A, Serra HA. Prescribing cascade. A proposed new way to evaluate it. Medicina (B Aires) 2017;77:13-6.  Back to cited text no. 7
Naylor M, Keating SA. Transitional care: Moving patients from one care setting to another. Am J Nurs 2008;108:58-63.  Back to cited text no. 8
Reus VI, Fochtmann LJ, Eyler AE, Hilty DM, Horvitz-Lennon M, Jibson MD, et al. The American psychiatric association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry 2016;173:543-6.  Back to cited text no. 9


  [Figure 1]

  [Table 1]

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