Study Identifies 24 Drug Combinations Triggering Dangerous 'Cascades' in Older Adults
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- Penelitian di Ontario mengidentifikasi 24 rangkaian resep berpotensi tidak tepat yang sering terjadi pada lansia.
- Efek samping obat yang dikira penyakit baru memicu penambahan obat lain, memperbesar risiko dan biaya.
- Sistem peringatan berbasis teknologi dan peran apoteker dinilai krusial untuk memutus rantai ini.
A large-scale study in Ontario, Canada, has revealed 24 sequences of drug prescriptions that could potentially harm older patients. These sequences occur when a drug's side effect is misinterpreted as a new illness, leading doctors to prescribe additional medication instead of re-evaluating the initial drug. The findings, published in The BMJ, highlight a practice that researchers call potentially inappropriate prescribing cascades (PIPC).
The research, which involved population prescription data from ICES, an Ontario health data institute, analyzed 65 candidate PIPCs compiled with 12 international experts. Of these, 24 were identified as sufficiently common and potentially harmful. Some cascades even affected more than one in ten patients who started the initial drug. These findings affirm that the problem is not merely the number of medications taken, but whether each drug has a clear indication and whether new symptoms have been appropriately evaluated.
According to Joyce Li, a researcher from Sinai Health Toronto, cascades are often missed because drug side effects resemble new medical conditions. "The timing varies; some appear within weeks, while others are only seen after several months," she stated. She added that the multitude of drug combinations and long-term use in older adults complicate identification in routine practice.
"If someone starts taking blood pressure medication and then develops swollen ankles, that swelling is treated with a diuretic without reviewing the original medication," explained Dr. Kanwar Kelley, an expert not involved in the study.
Kelley also highlighted healthcare fragmentation as exacerbating the situation. Patients often switch doctors, and no single practitioner has a complete record. "Symptoms often dismissed as part of aging—swelling, constipation, dizziness, nausea, and difficulty sleeping—could actually be drug side effects," she added. She emphasized that even if only a small fraction of cases are real, the total preventable harm remains significant.
For Indonesia, these findings are relevant given the prevalence of polypharmacy among older adults in the country. Data from the 2018 Basic Health Research (Riskesdas) shows that approximately 60% of older adults have multiple chronic diseases, which increases medication consumption. Unfortunately, integrated electronic medical record systems are not yet widespread. In many healthcare facilities, patient medication histories are still scattered across various paper prescriptions, making the risk of cascades difficult to detect. Community pharmacists could actually play a screening role, but their clinical authority is still limited.
The solutions offered by the researchers include utilizing clinical decision support systems linked to electronic medical records. These tools can provide alerts when a new drug is prescribed for symptoms that might be side effects of a previous medication. Li stated that their findings form the basis for developing such devices. However, Kelley cautioned about the importance of prioritizing alerts to prevent alarm fatigue. "Flag all 65, and doctors will ignore them; flag the important 24, and then they'll read them," she asserted.
Beyond technology, the involvement of pharmacists in the prescribing and medication review process is considered crucial. Patients are also encouraged to keep an up-to-date list of their medications, including when they were started, why they were prescribed, and by whom. Li suggested patients ask: "Are all these medications still necessary?" or "Could this new symptom be a side effect of a medication I'm already taking?"
Moving forward, the biggest challenge is not just providing the tools, but ensuring there is time and willingness to act on the alerts. Without cross-facility integration and a shift in work culture, prescribing cascades will continue to be a silent danger for older adults. Can Indonesia's healthcare system learn from these findings before the burden of non-communicable diseases further escalates?
