A Prescribing Cascade Involving Cholinesterase Inhibitors and Anticholinergic Drugs

Abstract

Optimizing the prescribing of medications for older adults remains a significant challenge for physicians and policy makers.¹ Efforts to improve prescribing have focused on potentially inappropriate drug use (ie, “errors of commission”),^2,3 the underuse of appropriate drugs (ie, “errors of omission”),^4-6 and drug interactions.³ However, more subtle mechanisms of inappropriate prescribing may also be important. Adverse drug events in older adults can manifest in a variety of ways, and such events may not always be correctly identified. Fried et al⁷ suggest that a misattribution model is a common illness presentation among older patients. Similarly, a “prescribing cascade” involves the misattribution of an adverse drug event to a new medical problem, leading to the inappropriate use of a second drug. Several examples of the prescribing cascade have been documented.⁸ We document a newly recognized prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs.