261 Perceptions of and attitudes towards problematic polypharmacy and prescribing cascades in older adults: a stakeholder analysis

Abstract

Abstract Background Research to date on appropriate prescribing in older adults has focused on characterising inappropriate prescribing using explicit prescribing indicator tools. Less is known about other causes of problematic polypharmacy such as prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat or to prevent the symptoms of an adverse drug reaction and may be characterised as intentional or unintentional, as well as appropriate or inappropriate. Prescribing cascades, therefore, represent an important and under-researched area of problematic polypharmacy. The aim of this study was to conduct a stakeholder analysis (patients with polypharmacy; carers; General Practitioners [GPs]; hospital doctors; community pharmacists; professional organisation representatives and policymakers) to elicit perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. Methods Qualitative one-to-one semi-structured interviews were conducted. Participants were recruited via a gatekeeper approach. Interview duration ranged from 58 to 80 minutes. Interviews were analysed thematically. Results Thirty-one participants (six patients, two carers, seven GPs, eight community pharmacists, four hospital doctors, two professional organisation representatives, and two policy makers) were interviewed. The challenges of communication at the interface of primary and secondary care were outlined, including the lack of clear ownership of drug monitoring. The community pharmacist and, at times, the patient were relied upon to fill in these gaps in communication. Patients discussed the burden of taking multiple medications. GPs described the importance of ‘mindful prescribing’ to avoid, where possible, unintentional prescribing cascades. The need for further education for health care professionals and patients on prescribing cascades was highlighted, as was the importance of improved collaboration between health care professionals. Conclusion Understanding the perceptions of different stakeholders towards problematic polypharmacy and prescribing cascades is key to the development of effective tools or resources to improve patient care.