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Prescribing Cascades: An Umbrella Review and Updated Systematic Review.
Massimo Carollo1,2, Salvatore Crisafulli1, Marta Zerio1
1Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy.
Drugs & Aging
|April 8, 2026
Summary
Prescribing cascades (PCs) are underrecognized, leading to inappropriate polypharmacy, particularly in older adults. This review synthesizes data on medications and adverse drug reactions (ADRs) involved in PCs to aid clinicians and researchers.
Area of Science:
- Pharmacology
- Geriatric Medicine
- Clinical Pharmacy
Background:
- Prescribing cascades (PCs) are frequently underrecognized, contributing to medication-related harm and increased healthcare costs.
- The complexity of polypharmacy, especially in older adults, exacerbates the issue of PCs.
Purpose of the Study:
- To synthesize existing knowledge on reported prescribing cascades (PCs).
- To identify specific medications and adverse drug reactions (ADRs) commonly involved in the initiation of PCs.
Main Methods:
- An umbrella review methodology was employed, integrating data from systematic and scoping reviews.
- An updated systematic review was conducted to capture recent studies up to July 2025.
- Databases searched included PubMed, Embase, Cochrane Library, Web of Science, and Scopus.
Main Results:
- 84 distinct adverse drug reactions (ADRs) potentially leading to PCs were identified.
- Key medication classes involved include antidepressants, antidementia drugs, antipsychotics, and antihypertensives.
- Psychiatric, nervous system, and gastrointestinal disorders were the most frequently reported ADR system organ classes.
Conclusions:
- Prescribing cascades are a significant, underrecognized factor in inappropriate polypharmacy, especially among the elderly.
- Current evidence on PCs is largely retrospective and heterogeneous, highlighting a need for standardized definitions and prevention strategies.
- This consolidated data serves as a crucial reference for healthcare professionals and researchers aiming to mitigate PC-related issues.
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