Prescribing cascades in persons with Alzheimer’s disease: engaging patients, caregivers, and providers in a qualitative evaluation of print educational materials

Abstract

Introduction: Prescribing cascades occur when the side effect of a drug is misinterpreted as a new medical condition, and a second drug is prescribed to address the side effect. Persons with Alzheimer’s disease (AD) are at increased risk of prescribing cascades due to greater multimorbidity, polypharmacy, and complexity of care. The objective of this study was to evaluate educational materials about prescribing cascades in persons with AD, and elicit input on their use in a future trial. Methods: We interviewed community-dwelling adults with either an AD diagnosis or a prescription drug used to treat AD ( n = 12), caregivers of patients meeting the same criteria ( n = 14), and providers ( n = 15). We coded interview transcripts and organized themes according to the communication–human information processing model. We revised the materials based on the interviews, and surveyed participating caregivers and providers for their reactions to the revised materials. Results: Analysis of patients’, caregivers’, and providers’ comments suggest: (a) Providers had conflicting views about the messaging of materials; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patient/caregiver-initiated conversations; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried that mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect the clinical encounter; (g) Participants felt that materials would improve patient/caregiver engagement. When surveyed, most providers found the revised materials informative and actionable, and most caregivers found them understandable and useful. Conclusions: This evaluation of educational materials about prescribing cascades in patients with AD provides strong support for engaging caregivers to communicate with providers about prescribing cascades. By giving patients and caregivers a basic description of the prescribing cascade concept, our educational materials may help them prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future trial. Lay summary Patient, caregiver and provider thoughts on educational materials about prescribing and medication safety Prescribing cascades occur when the side effect of a medication is misinterpreted as a new medical condition, and a second medication is prescribed to treat the side effect. Persons with Alzheimer’s disease (AD) are at increased risk of prescribing cascades because they often have more medical conditions, more medications, and more complex care. The goal of this study was to evaluate mailed educational materials about prescribing cascades in persons with AD, and get input on their use in a future study. We interviewed 12 adults with AD, or prescribed a medication to treat AD, 14 caregivers of persons with AD, and 15 providers. We reviewed the interview transcripts to identify important findings about our educational materials. We edited the materials based on the interviews, and sent participating caregivers and providers a questionnaire to get their reactions to the new materials. Important findings from the interviews suggest: (a) Providers had conflicting views about the recommendations given; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patients/caregivers introducing the topic; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect a doctor’s appointment; (g) Participants felt strongly that materials would improve patient/caregiver engagement. When surveyed, almost all providers found the revised materials informative and actionable; and most caregivers found them understandable and useful. These findings provide strong support for engaging caregivers to communicate with providers about prescribing cascades. The educational materials may help patients and caregivers prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future study.

Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system

“…Morris et al, in 2022 using the prescription sequence symmetry analysis (PSSA) methodology, identified 281 unique index drug—marker drug class dyads published as prescribing cascade signals 37 . While it is important to recognize the prescribing cascade signals identified by PSSA do not establish causality, some of the signals identified have been validated in formalized studies 44‐49 . In this study, we found that half of the index and marker drugs associated with the prescribing cascades signals involve a potentially inappropriate medication.…”

“Kind of blurry”: Deciphering clues to prevent, investigate and manage prescribing cascades

“…Further, despite widespread efforts to recruit for our self-referral stream, only two people self-referred for interviews. In our recruitment materials, we did not use the phrase ‘prescribing cascade’ specifically, which is a different approach than that used by Bloomstone and colleagues [ 33 ]. In their study, which developed and tested education materials for people living with dementia and their caregivers about prescribing cascades, investigators used an increasingly recognized cascade, calcium channel blocker → edema → diuretic, to introduce the concept.…”

Motivating deprescribing conversations for patients with Alzheimer’s disease and related dementias: a descriptive study

“…The findings from interviews with community-dwelling patients with ADRD, their caregivers, and providers offer further support for the feasibility of activating caregivers to participate in the deprescribing process using educational mailings. Bloomstone et al 29 found strong support for providing materials to encourage the caregivers to initiate a conversation with the provider about educational materials on prescribing cascades among patients with ADRD and caregivers but also identified a need to understand how the materials might motivate such a conversation. The study advances these findings in two ways.…”

“…Research also supports the importance of the patient/caregiver–provider communication to achieve clinical outcomes through engagement and shared decision-making. 29 , 31 – 33 …”

“…Research also supports the importance of the patient/caregiver-provider communication to achieve clinical outcomes through engagement and shared decision-making. 29,[31][32][33] Providers acknowledged the need to deprescribe potentially inappropriate medications for patients with ADRD, but seek effective clinical resources, alternatives to medications, and operational systems designed to support the deprescribing process within their practices. Providing such resources could help to address the known challenges that impede the deprescribing conversation, including time constraints, communication with multiple prescribers, and information management.…”