Identifying Key prescribing CASCADes in the Elderly: a transnational initiative on drug safety

Topic: Sex, Gender and Aging

Prescribing cascades occur when a health care provider misinterprets the side effect of a drug as a new medical condition and prescribes a second, potentially unnecessary, harmful drug to address the side effect. To improve the health of older adults, prescribing cascades must be identified and prevented. 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. In this international study, a team of experts in sex, gender and ageing will respond to this critical gap by applying a sex and gender lens to complementary health data from four countries. Specifically, we plan to evaluate whether men and women develop prescribing cascades in the same way and if there are differences in the ways they react from an adverse event. We will use administrative and clinical data on older adults to calculate prevalence rates for three prescribing cascades based on sex. We will also interview prescribers, patients and caregivers to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades. Findings will lead to a greater understanding of how adverse drug events differ between older women and men, and help us develop and spread tailored knowledge translation products to minimize the frequency and impact of prescribing cascades.

Project coordinator

Dr. Paula Rochon, MD, MPH, FRCPC, Vice President Research, Women’s College Hospital, Retired Teachers of Ontario Chair in Geriatric Medicine, Senior Scientist, Women’s College Research Institute, Professor, Department of Medicine, University of Toronto, Ontario, Canada


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

Institutions involved

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


Paula Rochon, MD, MPH, FRCPC, paula.rochon@wchospital.ca

More about the project on the Women’s College Hospital website

  • Dr. Paula Rochon, Project Coordinator of the iKASCADE transnational initiative, has launched Women’s Age Lab. The Lab, the first and only centre of its kind in the world, is a space for exploration and collaboration on science-driven health and social change that will improve the lives of older women. The aim is to enable researchers, healthcare providers and decision-makers, collectively with older women, to transform health and social care to positively impact their health and well-being. One of the four areas of focus of the Lab is to optimize drug therapies. As such, the work of iKASCADE – to identify and reduce prescribing cascades, a universal, yet under-researched, aspect of iatrogenic medication harm that particularly impacts older women – will contribute to Women’s Age Lab.
  • Many of the senior leadership of the iKASCADE research group will be meeting in London, UK at the at the 18th international European Geriatrics Medicine Society Congress, to be held late this September. This is the investigators’ annual meeting to discuss the progress of the project. Three abstracts in relation to the iKASCADE study were accepted for presentation at the 2022 EuGMS Conference.
  • The Team has created a tool for identifying clinically important prescribing cascades affecting older people called “ThinkCascades”. A paper on this tool has been accepted for publication by Drugs & Ageing and has been the subject of an oral presentation at the International Conference on Deprescribing in September 2022 by Dr. Lisa McCarthy.
  • Dr. Robin Mason, a Senior Researcher on the iKASCADE Team, has spearheaded the creation of “What Gets Counted Counts: Paying Attention to Sex and Age in Health Research.” This recently launched, interactive online module is designed to raise awareness among research scientists as to why disaggregating data by sex and age in health research is important.

Objective updates

  • Knowledge translation of iKASCADE’s Objective 1 is well under way. This objective used an international modified Delphi process in order to develop an expert consensus-based short list of clinically important prescribing cascades (i.e., where risks of the prescribing cascade usually exceed benefits) impacting older people. This work is now complete. A manuscript detailing this Objective is currently under consideration for publication in Drugs & Aging, a peer-reviewed journal that publishes on drug therapy for an audience of researchers and healthcare professionals involved in the care of older patients. This work has also been presented at the 26th Congress of the European Association of Hospital Pharmacy in Vienna (March 2022) and will be presented at the American Geriatrics Society Meeting in Florida (May 2022).
  • The Objective 2 of the iKASCADE project is to utilize country-specific, complementary data sources to measure sex-stratified prevalence rates of nine key prescribing cascades and explore sex and gender differences in how prescribing cascades are experienced in different settings of care (community, hospital, or long-term care). We are well into this objective – data has been shared from Ireland, Israel and Italy, and we are in the midst of compiling this data in a comparative way with data from Canada.
  • We are on the cusp of launching a qualitative study in order to examine the role of gender in the development and maintenance of prescribing cascades, a goal that cuts across study objectives. The design of this innovative study was collaboratively produced, and the study itself will be run in Canada, Italy and Ireland. Results are anticipated for the end of the Summer 2022.