For Healthcare Professionals:
A new study from Ireland highlights frequent prescription cascades in older adults – also with vestibular relevance:
Background
Prescription cascades occur when a side effect of a drug is misinterpreted as a new medical condition—and then treated with an additional medication. Older adults with multimorbidity and polypharmacy are particularly at risk. This new analysis of Irish prescription data examined 9 such cascades for the first time in more than 530,000 people aged ≥65 years.
Study design
- Source: : National Prescription Database of Ireland (GMS Scheme)
- Method: Prescription Sequence Symmetry Analysis
- Observation window: 365 days
- Population: 533,464 older adults (≥65 years)
The five most common prescription cascades – clinically explained
1. Antihypertensive → Diuretic
Frequency: 2.6% | Risk nearly doubled (aSR 1.93)
Typical case:
A calcium channel blocker lowers blood pressure but causes peripheral edema. Instead of switching the drug, a diuretic is added.
Consequence:
→ Electrolyte disturbances, circulatory problems, dizziness.
2. Prostate medication → Vestibular sedative (for dizziness)
Frequency: 3.0% | Risk increased by 63% (aSR 1.63)
Typical case:
An α1-blocker for benign prostatic hyperplasia lowers blood pressure and leads to orthostatic dizziness. Instead of reducing the dose, a vestibular sedative is prescribed—even though no vestibular disorder is present.
Consequence:
→ Central balance processing is dampened, gait instability increases, fall risk rises.
3. Antidepressant → Sleeping pill
Frequency: 2.5% | Risk increased by 54% (aSR 1.54)
Typical case:
A patient starts an SSRI or SNRI and develops sleep problems. Instead of adjusting therapy, a sleeping pill is added.
Consequence:
→ Daytime drowsiness, fall risk, risk of dependence.
4. Antipsychotic → Parkinson’s medication
Frequency: 0.4% | Risk increased by 20% (aSR 1.20)
Typical case:
An antipsychotic causes extrapyramidal symptoms (e.g., rigidity, tremor). These are treated with an antiparkinsonian drug.
Consequence:
→ Burden on the dopaminergic system, new side effects.
5. Tranquilizer → Antipsychotic
Frequency: 3.2% | Risk increased by 15% (aSR 1.15)
Typical case:
A benzodiazepine triggers a paradoxical reaction (restlessness, confusion). This leads to the prescription of a neuroleptic.
Consequence:
→ Sedation, gait disorders, delirium risk.
Clinical implications
- Dizziness, sleep problems, or confusion should always be critically assessed for possible side effects.
- Vestibular sedatives are frequently prescribed for nonspecific dizziness—without vestibular diagnostics.
- Prescription cascades increase fall risk, reduce quality of life, and promote functional decline.
Conclusion
Prescription cascades are frequent and clinically relevant—especially in the geriatric context with balance disorders. For physiotherapists, physicians, and pharmacists, careful assessment of every new symptom is essential.
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For Patients – Easy to Understand
The five most common prescription cascades – simply explained
1. Blood pressure medication → Water pill
Frequency: 2.6%
What happens?
A blood pressure drug (calcium channel blocker) can cause swelling in the legs. Instead of adjusting the medication, a water pill (diuretic) is prescribed.
Consequence:
Mineral imbalance, circulatory problems, dizziness—and higher fall risk.
2. Prostate medication → Dizziness drug
Frequency: 3.0%
What happens?
A prostate drug can lower blood pressure—especially when standing up—causing dizziness. Instead of solving the cause, a dizziness drug is prescribed—even though the balance organ is healthy.
Consequence:
The dizziness drug dampens brain areas that control balance. You feel unsteady—and the fall risk increases.
👉 Important: These dizziness drugs are only for acute emergencies—and never for more than a few days!
3. Antidepressant → Sleeping pill
Frequency: 2.5%
What happens?
A new antidepressant causes sleep problems. Instead of adjusting treatment, a sleeping pill is prescribed.
Consequence:
Daytime fatigue, unsteadiness—or dependence on the sleeping pill.
4. Medication for psychological symptoms → Parkinson’s drug
Frequency: 0.4%
What happens?
A drug for hallucinations or severe restlessness can cause muscle stiffness or tremors. Instead of reviewing that medication, a Parkinson’s drug is prescribed.
Consequence:
More drugs, unnecessary Parkinson’s medication, and new side effects.
5. Tranquilizer → Antipsychotic (neuroleptic)
Frequency: 3.2%
What happens?
A tranquilizer (e.g., benzodiazepine) can paradoxically cause restlessness or hallucinations. Another strong drug (neuroleptic) is then prescribed.
Consequence:
Fatigue, unsteadiness, concentration issues.
What you can do
Talk openly about your complaints.
If you notice new symptoms, consult your doctor.
Ask directly: “Could this be a side effect of my medication?”
Get a second opinion
— for example, from your pharmacist.
In case of dizziness or balance problems:
If your complaints are not caused by medication, a vestibular disorder may be the underlying reason.
🎯 Our certified IVRT® dizziness and vestibular therapists can provide individual support: IVRT therapist search