How are prescribing cascades defined in the literature? A scoping review

Introduction: Prescribing cascades are important medication-related issues to be aware of, particularly for multimorbid older adults with polypharmacy. These cascades were initially defined as phenomena where side effect misinterpretation results in the prescribing of additional medications. This definition has been debated though, particularly on whether side effects may be misinterpreted or recognised/unrecognised, and consequently whether cascades are intentional/unintentional. Given these inconsistencies, this scoping review aimed to map how prescribing cascades have been defined and described in the published literature. Methods: Seven electronic databases were searched from inception to October 2024. Full-text publications in English that mentioned prescribing cascade (or a synonym) in the title or abstract and provided a prescribing cascade definition/description in the full text were included. Specific terminology and images used to define/describe prescribing cascades were extracted, and the findings were narratively synthesised. Results: Of the 139 included publications, less than half directly aligned with the original definition by containing descriptions of prescribing cascades that indicated side effect misinterpretation (48.9%). One quarter indicated side effects could be recognised or unrecognised (24.5%), 37.4% addressed cascade appropriateness or inappropriateness, and 8.6% referenced their intentional or unintentional nature. One fifth (20.9%) included an image or map to describe a prescribing cascade. Conclusion: This review has uniquely mapped how prescribing cascades have been described in the literature, finding substantial heterogeneity between publications. By highlighting this inconsistent terminology use, this review emphasises the need to develop consensus definitions to aid in the future recognition, measurement, education, and prevention of prescribing cascades.