iKASCADE Project

This project, Identifying Key Prescribing CASCADes in the Elderly: A Transnational Initiative on Drug Safety (iKASCADE)is exploring how older women, men and gender-diverse individuals are affected differently by prescribing cascades and how prescribers treat their patients based on sex and gender. As outlined in the graphic below, prescribing cascades are common and happen when the side effect of a medication is treated with a potentially unnecessary and harmful second drug.  

Since women live longer than men, they are more likely to be prescribed inappropriate drug therapies and experience more drug-related adverse events. To interrupt prescribing cascades, there is a need to understand sex and gender differences. Despite the pervasiveness of prescribing cascades, little is known about their presentation or management and whether differences persist across countries. As such, the international iKASCADE team is working to bridge this critical knowledge gap. 

Findings from this project will improve widespread understanding of how adverse drug events are different between older women, men and gender-diverse people across various settings (hospital, long-term care, community) and countries, and inform the development and dissemination of knowledge and tools to reduce the frequency and impact of prescribing cascades. 

To learn more, please watch this video with the project's Primary Investigator, Dr. Paula Rochon.

Cascading Diagram


Countries & Institutions Involved 

The iKASCADE project is one of 13 transnational projects selected for funding by the prestigious, international GENDER-NET Plus consortium. This specific project involves a collaboration between five different countries and nine institutions. 

Countries: Belgium, Canada, Ireland, Israel, Italy, USA. 

Institutions: Women’s College Hospital, University of Toronto, University College Cork (Ireland), Istituto nazionale di ricovero e cura dell’anziano (Italy), Clalit Research Institute (Israel), University of Massachusetts (USA), University of Bologa (Italy), University of Sacro Cuore (Italy), University of Ghent (Belgium). 

Gendernet plus logo


Partner Webpages 

Learn more about how our international partner organizations are helping to bridge knowledge gaps around aging and the healthcare needs of older adults. 

USAThe Aging Initiative 

The goal of the HCSRN-OAICs (Health Care Systems Research Network-Older Americans Independence Centers) AGING (Advancing Geriatrics Infrastructure & Network Growth) Initiative is to create a national resource to advance an interdisciplinary research agenda focused on older adults with multiple chronic conditions. Efforts of the AGING Initiative will lay the foundation to address the knowledge gaps that exist regarding the health and healthcare of these understudied patients. 


Data Collection Methods 

To collect data and create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the iKASCADE team: 

1) Has created a modified Delphi procedure where international experts in prescribing will rank a list of prescribing cascades as to their clinical importance. 

2) Is using administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex across five countries, in the hospital, long-term care and community settings. 

3) Is using interviews and realistic, country-specific vignettes (each incorporating a prescribing cascade with identified sex differences) to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades. 

close up of a paper with a graph


Expected Outcomes & Current Findings 

Concrete outcomes from the iKASCADE project include the development of an inventory of common prescribing cascades; detailed understanding of sex-specific prescribing cascades in hospital, long-term care, and community settings; greater understanding of similarities or differences regarding prescribing cascades in six countries; and a nascent understanding of the ways in which gender dimensions may influence the development or treatment of prescribing cascades. 

Data collection and analyses is ongoing, but to date the team has identified over 100 prescribing cascades. Currently there are few methods that examine gender inequities in countries with a high socio-economic status, so the team is adapting a framework to do this that can be used by others. 


Publications & Presentations 

Publications 

British Medical JournalUsing a clinical process map to identify prescribing cascades in your patient 

Canadian Medical Association Journal-Prescribing cascades in older adults 

Canadian Medical Association Journal - Prescribing cascades in older adults podcast 

JAMA Internal Medicine - Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension 

JAMA Internal Medicine - Antihypertensive Prescribing Cascades as High-Priority Targets for Deprescribing 

Journal of American Geriatrics Society What Is Known About Preventing, Detecting, and Reversing Prescribing Cascades: A Scoping Review 

Journal of American Geriatrics Society Assessing the Scope and Appropriateness of Prescribing Cascades 

The Lancet - The Prescribing Cascade Revisited 

New York Times The Risks of the Prescribing Cascade 

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

Accepted/In Press 

Sternberg S, Guy-Alfandary S, Rochon PA. Five Things to Know About Prescribing Cascades in Older Adults. CMAJ. 2021. 

Sternberg SA, Rochon PA, Gurwitz JG. Focusing on medications that increase the risk of falls in older adults. [Invited Editorial]. Accepted to European Geriatric Medicine Journal. Dec 26 2020. 

Presentations 

Identifying Key Prescribing Cascades in the Elderly Symposium: A Transnational Initiative on Drug Safety. International Congress of the European Union Geriatric Medical Society. September 27, 2019. Krakow, Poland.  

Exploring Common Prescribing Cascades Among Older Women and Men in Three Key Settings of Care: A Transnational Initiative on Drug Safety. Special Interest Group in Geriatric Pharmacology, International Congress of the European Union Geriatric Medical Society. September 28, 2019. Krakow, Poland.  


Funding 

The iKASCADE project has received federal funding from the Canadian Institutes of Health Research (CIHR) and from the federal funding agencies of the international partners, as well as funding from GENDER-NET Plus

Fully affiliated with

A member of

Council of Academic Hospitals of Ontario (CAHO)