Sort the medication list by start date. That is the whole technique, and it takes about five minutes.
Why sort a medication list by start date?
A list sorted alphabetically, or grouped by drug class, is optimized for finding a drug you already have in mind. A list sorted by the date it was started is optimized for finding a pattern — and the two most consequential patterns in a long medication list are both patterns in time.
What is a prescribing cascade?
A drug causes a symptom. The symptom is read as a new condition. The new condition is treated. Every step is defensible; nobody made an error; and the sequence is invisible unless somebody looks at the order.
What you are looking for is a medication started within weeks to a few months of another, treating a recognized effect of the earlier one, with no note recording that the earlier drug was reconsidered first. That last part is the diagnostic bit. “Reviewed X, symptom persisted, adding Y” is not a cascade. Silence is.
What is a drug substitution?
The other pattern is a drug appearing as another one is reduced. It is easy to miss because it looks like success on the class you were watching.
The clearest documented example: among Ontario nursing home residents dispensed an opioid between 2009 and 2020, concurrent benzodiazepine use fell by 53.2% in relative terms while concurrent gabapentinoid use rose by 505.4%. In US nursing homes in 2021, gabapentin was the agent most frequently involved in central nervous system polypharmacy. A class was reduced and the burden reappeared under a different heading.
How do you find a prescribing cascade in a medication list?
For every drug started in the past two years, ask what happened in the eight weeks before it. That is it. It is the highest-yield five minutes available in a medication review, and it requires no tool.
Read more: Prescribing cascades · The medication review.
Frequently asked questions
How can you tell a prescribing cascade from a justified new prescription?
Read the notes. A cascade is a medication started within weeks to a few months of another, treating a recognized effect of the earlier drug, with no record that the earlier drug was reconsidered first. A note that says the earlier drug was reviewed, the symptom persisted, and a new drug was added is not a cascade. Silence is.
Why is a prescribing cascade so hard to spot?
Every step looks reasonable on its own. A drug causes a symptom, the symptom is read as a new condition, and the new condition is treated. Nobody made an error, so nothing gets flagged. The sequence only shows up when someone looks at the order in which the drugs were started.
What does it mean when a new drug appears as another is reduced?
That is a substitution, and it can look like success on the drug class being watched. Among Ontario nursing home residents dispensed an opioid from 2009 to 2020, concurrent benzodiazepine use fell 53.2% in relative terms while concurrent gabapentinoid use rose 505.4%. The class was reduced, and the burden reappeared under a different heading.
How long does a medication list review for cascades take?
The date-order check takes about five minutes and needs no special tool. Sort the list by start date. For every drug started in the past two years, ask what happened in the eight weeks before it. It is the highest-yield five minutes available in a medication review.
References
- Hogan DB, Campitelli MA, Bronskill SE, et al. Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents. Journal of the American Geriatrics Society. 2023;71(8):2462–2475. PMID 36942992 · DOI 10.1111/jgs.18320.
- Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
- By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.
Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.