There is a pattern happening inside Australian aged care facilities that affects one in four residents, increases their risk of serious harm and has a name most families have never heard of.

It is called a prescribing cascade – and new research from some of Australia’s leading aged care researchers suggests it is far more common, and far more dangerous, than most people realise.

What is a prescribing cascade?

The concept is straightforward, even if the consequences are not. A prescribing cascade occurs when the side effect of a medication is mistaken for a new medical condition, and a second medication is prescribed to treat it. That second medication may itself produce side effects, which may then be treated with a third medication – and so on.

Over time, the number of medications a person is taking grows, each one adding complexity, increasing the risk of further side effects and making it progressively harder to identify which drug is causing which problem. It is a cycle that can quietly compound until a person is taking a significant number of medications, some of which may be doing more harm than good.

What the research found

The study, led by the Registry of Senior Australians Research Centre at SAHMRI and Flinders University and published in the journal Age and Ageing, analysed the medication records of more than 167,000 Australians aged 65 and over who entered long-term residential care facilities.

The findings are striking. Before entering aged care, 16.7 per cent of residents had already experienced at least one prescribing cascade. After admission, that figure rose to 25.1 per cent – meaning one in four residents was caught in a cycle of medications being prescribed to treat the side effects of other medications.

Many of the prescribing cascades involved medications already recognised as high-risk in older populations, including antipsychotics, benzodiazepines and opioids – drugs that carry well-documented risks of falls, confusion, sedation and cognitive decline in elderly patients.

Why it gets worse when people enter aged care

The transition into residential aged care is one of the most vulnerable periods for medication safety. Medication regimens often change significantly at this point, residents may be seen by new doctors who are not familiar with their full history, and declining health or increased frailty can trigger new prescriptions.

Lead researcher Professor Gill Caughey says treatment decisions can easily compound in this environment.

“What we’re seeing is that many residents are exposed to patterns of prescribing that may unintentionally lead to harm,” Professor Caughey said. “While some prescribing may be appropriate, we found many prescribing cascades that involved medications deemed inappropriate by international guidelines for the older population.”

People living with dementia face even greater risk

The study found additional prescribing cascades among people living with dementia, many linked to sleep disturbance and sedation. For a person whose cognitive function is already compromised, the addition of sedating medications carries particular risks – including increased confusion, falls and accelerated cognitive decline.

“For people living with dementia, the risks can be even more complex,” Professor Caughey said.

The challenge is that many of the symptoms being treated with additional medications – sleep problems, agitation, restlessness – may themselves be side effects of existing prescriptions rather than new conditions requiring new drugs. Without careful review, the cascade continues.

What families should know — and what they can do

For the millions of Australian families with a loved one in residential aged care, or approaching that transition, this research carries a practical message: ask about the medications.

Specifically, families can ask the following questions at any medication review or GP appointment:

• Has every medication been reviewed recently, and is each one still necessary?
• Could any current symptoms – particularly drowsiness, confusion, dizziness, sleep disturbance or changes in behaviour – be a side effect of an existing medication rather than a new condition?
• Is there an opportunity to reduce the number of medications through deprescribing – the supervised, gradual withdrawal of medications that may no longer be needed or may be causing more harm than benefit?

Professor Caughey says the research points to a clear opportunity for intervention.

“There’s a real opportunity here to intervene earlier through routine medication reviews, better monitoring of side effects and, where appropriate, deprescribing strategies,” she said. “Improving awareness of prescribing cascades among clinicians and care teams can help ensure we’re treating the root cause of symptoms, rather than unintentionally adding to the burden of care.”

The bigger picture

Australia’s aged care system has been under intense scrutiny since the Royal Commission into Aged Care Quality and Safety delivered its findings in 2021. Medication management was identified as a significant concern, with the Commission recommending stronger safeguards around prescribing practices in residential care.

This latest research suggests that while awareness is growing, the problem persists – and that the transition into care remains a critical moment where medication safety can go wrong.

For older Australians and their families, the takeaway is not to be alarmed, but to be informed. Medications save lives and manage conditions that would otherwise cause significant suffering. But every medication carries risks, and the more medications a person takes, the more important it becomes that someone – a GP, a pharmacist, a geriatrician, a family member — is asking whether each one is still doing what it was prescribed to do.

One in four aged care residents is caught in a prescribing cascade. That is a number worth knowing.