Overlooked Prescribing Cascades Drive Harm in Older Adults

Background: Prescribing cascades—when an adverse drug effect is misinterpreted as a new medical condition and treated with an additional medication—are an underrecognized contributor to polypharmacy and harm among older adults. Objective: To examine clinician decision-making and downstream outcomes associated with the gabapentinoid–loop diuretic (LD) prescribing cascade among older adults. Design: Cohort study involving structured medical record review of a randomly selected sample of U.S. veterans aged ≥66 years who potentially experienced a gabapentinoid–LD prescribing cascade between January 1, 2013, and August 31, 2019. Methods: Data abstraction and analysis were conducted from October 24, 2023, to July 22, 2025. The exposure was initiation of a gabapentinoid (gabapentin or pregabalin) followed by initiation of a loop diuretic. Abstractors reviewed clinical documentation in the 30 days before and 60 days after LD initiation to assess clinician reasoning more...