The Prescribing Cascade

May 2026 – Why is it that more falls tend to occur in older adults? Many assume it is just a product of aging. However, there is a lot that can be done to minimize the risk of falls as we age.  This includes maintaining physical conditioning through weight-bearing exercises, a quality diet with adequate protein, balance exercises, and addressing one of the biggest risks; medications.

Research has shown that taking multiple medications, or polypharmacy, may be a risk factor for falling. One such study showed that taking 5 or more medications increased your risk of falling over a 2-year period by 21%. Taking certain high-risk drugs such as opioids for pain, benzodiazepines for anxiety, medications used to manage high blood pressure, or even anticholinergics for allergies can increase your risk of falls even more significantly. Four or more of those types of drugs, referred to as FRIDs (Fall Risk Increasing Drugs), can more than double your risk of a fall.

How do some people end up on so many medications? 

As we age, we have a greater risk of developing chronic diseases requiring more medications. But even those without chronic disease are at risk. 

Let’s look at an example of a patient over the age of 65 who has a diagnosis of depression. They are prescribed an SSRI to treat depression. The depression symptoms improve, but they are having difficulty sleeping due to taking the mediation at bedtime. They go to the over-the-counter (OTC) area and find diphenhydramine (generic for Benadryl) which is a common ingredient in sleep aids. This is in a class of medications called anticholinergics, also used for allergies. This may cause sleepiness, unsteady gait and ultimately falls.  A side effect may also be urinary retention.

They visit the primary care doctor to assist with the urinary retention, but don’t list their OTC medications. The physician suggests a medication for urinary retention. The most common and least expensive also have an anticholinergic component, which further complicates the fall risk. The urinary retention does not improve, and they are prescribed a diuretic to further assist with urination. This works, but in the middle of the night, heading to the bathroom, they fall and suffer a broken rib. To treat the pain, they are started on an opioid medication which further elevates their risk of falling.

This is how many patients end up on multiple medications, also referred to as the prescribing cascade.

How could this have been avoided?

1.  Ask the pharmacist about side effects. Knowing that it may impair sleep, they may advise taking the antidepressant in the morning, eliminating the need for a sleep aid.
2. If you start an OTC medication, make sure your physician and pharmacist are aware.  Had the physician been aware of the diphenhydramine, they may have simply stopped that medication, rather than prescribing medication for urinary retention (a diuretic) and reduce fall risk.
3. If taking opioids for acute pain, be sure to limit the time you use it to only what is needed; generally, 7 days or less.
4. If you are worried about the number of medications you are on, consult your physician or pharmacist. 
5. Be sure to get all prescription medications from one pharmacy so they can better address potential drug interaction or side effects.

Ask your physician or pharmacist if you are concerned about the number of medications you are taking. Reducing the list by even one or two medications may significantly reduce your risk of falls.