Prescribing cascades potentially associated with harms before and after transition to long-term care facilities

Transition to long-term care facilities (LTCFs) is a critical period associated with increases in medication errors and adverse events, yet our knowledge of prescribing cascades in the older population during this period is limited. The objective was to identify prescribing cascades potentially associated with harm in LTCF residents before and after care entry.

A retrospective population-based cohort study of 167 850 individuals aged 65 years or older who entered 2771 LTCFs nationally between January 2018 and June 2020 was conducted. Prescription sequence symmetry analysis was used to examine 142 prescribing cascades with a 12-month exposure window between the index and marker medicines.

Among 167 850 residents, 16.7% (n = 28 018) had at least one statistically significant prescribing cascade before transition to LTCF and 25.1% (n = 42 101) after LTCF, with little difference in prevalence when stratified by dementia status. Before LTCF entry, initiation of statins was associated with initiation of multiple medications [e.g. antipsychotics adjusted sequence ratio (aSR) 2.97, 95% confidence interval (CI) 2.58-3.41], antidepressants (aSR 1.60, 95% CI 1.45-1.76) and benzodiazepines were associated with initiation of antipsychotics (aSR 1.43, 95% CI 1.35-1.52). After LTCF entry, initiation of statins was associated with multiple medications (e.g. antipsychotics aSR 2.93, 95% CI: 2.59-3.3 and antidepressants aSR 2.29, 95% CI: 2.05-2.56). Initiation of benzodiazepines was associated with antipsychotics (aSR 1.53, 95% CI: 1.47-1.59). Six cascades prior to LTCF entry and 13 after were unique to residents living with dementia with many associated with insomnia/sedation.

This national population-based study identified prescribing patterns consistent with potential prescribing cascades during a vulnerable care transition.