Pulse ·

Prescribing cascades spike when older patients move into aged care

By Dr HB Lo, FACRRM 4 min read
Verdict Yes — worth knowing about

A June 2026 study of 167,850 Australians aged 65 and over found prescribing cascades — where a new drug treats what appears to be a new condition but is actually an adverse effect of an existing drug — rose from 16.7% before aged care entry to 25.1% after. The increase was consistent regardless of dementia status.

High-risk medications including antipsychotics, benzodiazepines, and opioids were frequently involved. Research led by the Registry of Senior Australians, Flinders University, published in Age and Ageing.

Aged care entry should trigger a medication reconciliation review involving the GP and pharmacist, with deprescribing where appropriate.

What just happened

A study published in Age and Ageing in June 2026 has mapped what happens to medication regimens when older Australians move into residential aged care — and the result is a clear warning about a vulnerable transition point. Among 167,850 Australians aged 65 and over, the rate of prescribing cascades rose from 16.7% before aged care entry to 25.1% after it. The increase was consistent whether or not patients had dementia.

A prescribing cascade, as defined by Australian Prescriber, occurs when a new medication is started to treat what appears to be a separate medical condition — but what is actually an adverse reaction to an existing drug. The patient ends up on more medications. The original adverse effect goes unaddressed. The pile grows.

The research was led by the Registry of Senior Australians Research Centre at South Australian Health and Medical Research Institute and Flinders University. Professor Gill Caughey, the lead researcher, described aged care entry as “one of the most vulnerable periods for older people” in relation to medication safety. High-risk medications involved in the cascade patterns included antipsychotics, benzodiazepines, and opioids — all drug classes where adverse effects in older people can present as exactly the kind of symptoms that might prompt a new prescription: confusion, falls, sleep disturbance, agitation, constipation.

Dr Anthony Marinucci, Chair of RACGP Specific Interests Aged Care, responded with a concrete recommendation: aged care entry “should trigger medication reconciliation and timely, coordinated review involving the GP and pharmacist, with deprescribing where appropriate.” He also noted the important caveat that the data shows prescribing patterns, not proven causation — correlation between aged care entry and cascade risk does not prove that the transition is causing the cascades rather than reflecting the complexity of the patients who are entering care.

The both-and

Why the 16.7% to 25.1% jump is significant

The shift from 16.7% to 25.1% represents approximately a 50% increase in the rate of prescribing cascades at a transition that every Australian entering aged care goes through. The mechanism is not hard to understand. Residential aged care entry involves a handover of prescribing responsibility — usually from a community GP who has known the patient for years to a different clinical structure, often with different prescribers, different documentation systems, and different pharmacists. Medication lists may not transfer completely. Context — “we tried that five years ago and it caused X” — does not always travel with the file.

At the same time, the patient is experiencing significant physiological and psychological stress from the transition itself. New symptoms emerge. Some are genuine new conditions. Some are adverse drug reactions that, in a context of complete medication history, would be identifiable as such. Without that history, and without a structured review that actively looks for cascade patterns, they get treated with new prescriptions rather than adjusted or ceased existing ones.

This is a systems problem as much as an individual clinical problem. Aged care pharmacy services exist but are unevenly distributed. Medication reconciliation at transition is recommended but not universally mandated. GPs managing patients in residential aged care are often working with limited consultation time and incomplete information.

What the data cannot tell us

The study design is retrospective — it looks at what happened to medication records, not why. Dr Marinucci’s caveat is important: patients who are entering residential aged care are typically in a phase of declining health and increasing medical complexity. Higher prescribing cascade rates in the post-entry period may partly reflect the natural trajectory of multi-morbidity rather than something uniquely introduced by the care transition itself.

This does not diminish the clinical implication. Whether the cause is the transition, the patient’s underlying trajectory, or the prescribing environment of residential aged care, the result is the same: a higher burden of potentially harmful medication patterns in a population that is already at elevated risk. The question for clinicians is not “what caused this?” but “what can we do about it at the point of entry, while we have the opportunity to look?“

2 cents

If you have an older family member who is approaching or has recently gone through the move into residential aged care, one of the most useful things you can do is ask about their medication list. Specifically: has there been a medication review since the transition? Has anything new been prescribed in the past few months? Is there someone — a GP, a pharmacist, or an aged care pharmacist service — who has checked whether any new symptoms could be adverse effects of existing drugs rather than new conditions?

These are the questions that close prescribing cascades before they deepen. They are not clinical questions that require medical training to ask. They are good questions, and the right time to ask them is now.

Verdict: yes — worth knowing about.

Sources cited

  1. RACGP newsGP — Study flags medication risk during aged care transition. June 2026. https://www1.racgp.org.au/newsgp/clinical/study-flags-medication-risk-during-aged-care-trans
  2. Age and Ageing — Prescribing cascades study. June 2026. https://academic.oup.com/ageing/article/55/6/afag166/8711293
  3. Australian Prescriber — Prescribing cascades. https://www.australianprescriber.tg.org.au/

Frequently asked questions

  • What is a prescribing cascade and why does it matter for older people?

    A prescribing cascade happens when a new medication is prescribed to treat symptoms that are actually side effects of an existing medication — so the patient ends up on more drugs, not fewer, and the underlying problem (the original drug's adverse effect) goes unaddressed. In older people, this is particularly dangerous because polypharmacy is already common, adverse drug reactions are harder to detect (symptoms can mimic ageing), and each additional drug adds to the interaction risk. The study published in Age and Ageing found the rate of prescribing cascades rose substantially at the transition into residential aged care — a period when medication reviews are particularly important.

  • What should families and GPs do when an older person enters residential aged care?

    Aged care entry is a recognised high-risk transition for medication safety. The RACGP recommends that it should trigger a formal medication reconciliation review — a structured process where all current medications are listed, assessed against current indications and recent changes in clinical status, and deprescribed where appropriate. GPs and pharmacists should work together in this review. If a new symptom appears shortly after aged care entry, it is worth asking whether it could represent an adverse drug reaction rather than a new medical condition — that question is the first step to preventing a prescribing cascade.