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 Table of Contents    
Year : 2016  |  Volume : 48  |  Issue : 3  |  Page : 334-335

Prescription cascading in developmentally disabled individuals

1 Department of Biopharmaceutical Sciences, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA 22601, USA
2 Department of Pharmacy Practice, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA 22601, USA

Date of Web Publication23-May-2016

Correspondence Address:
Dr. Isha Patel
Department of Biopharmaceutical Sciences, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA 22601
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7613.182893

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How to cite this article:
Patel I, Trinh S, Phan T, Johnson M. Prescription cascading in developmentally disabled individuals. Indian J Pharmacol 2016;48:334-5

How to cite this URL:
Patel I, Trinh S, Phan T, Johnson M. Prescription cascading in developmentally disabled individuals. Indian J Pharmacol [serial online] 2016 [cited 2023 Sep 28];48:334-5. Available from: https://www.ijp-online.com/text.asp?2016/48/3/334/182893


Prescription cascading occurs when a patient is prescribed a new medication in order to treat the side effect or adverse reaction from another medication that they are taking. This could be due to the failure of a health professional to recognize an adverse drug event associated with a medication or it could be due to a misdiagnosis of a new medical condition that requires treatment.[1] Prescription cascading is associated with risky medications prescribed for conditions such as dementia, hypertension, insomnia, pain management, epilepsy, nausea, and bacterial infections. Developmentally disabled individuals have a high prevalence of chronic disease conditions, including some of the above stated conditions.[2] In addition due to patients' limited mobility and cognition, they may not be able to communicate their symptoms. Medication prescribing is a complex decision; hence, it is very important to consider all aspects of patient care prior to making the most appropriate choice. Pharmacists can assist in reducing prescription cascading by keeping records of all dispensed medications, and monitoring patient medication regimens for possible drug interactions or any medication-related problems.[3] Medication therapy should be appropriate, safe, and effective.[4] Pharmacists should contact the patient's primary care provider if they suspect any prescription cascading is occurring.

Along with meeting the patient's caregiver, a family member or a case manager who is responsible for providing medications to the patient, communicating directly with the patient can provide an insight into the complex care that these patients need on a continuous basis. The role of each care provider in the patient's life can also be better understood.[5] In spite of pharmacists encountering communication barriers with patients, these patients have varying ranges of intelligence. Hence, asking open-ended questions and providing advice to the patient can be an effective way of understanding their health issues and conveying useful information that can aid the patient and the caregiver in disease management. Patients' quality of care can improve as a result of the pharmacist building a working relationship with them and becoming attuned to their medication therapy-related issues.[4]

Pharmacists can act as a liaison between the developmentally disabled patients and other health-care providers, caregivers, and family members. Pharmacists can provide cognitive services and expertise to create a difference in the disease management of patients with developmentally disabled and chronic conditions.[6] A pharmacist can take part in medication therapy management and play an integral part of medication reconciliation and transitions of care.[4] In addition, pharmacists can provide patient counseling about medication intake, medication storage, and medication dose adjustment in consultation with the patient's primary care physician to limit adverse events and thereby medication cascading.[3] Because of their expertise in pharmacotherapy, they may be able to reduce instances of prescription cascading in disabled populations. Developmentally disabled patients visit several physicians for their multiple health issues and generally spend 15 min or less with their physicians which might not be sufficient to tend to all their problems. Also, in the case of developmentally disabled patients seeing a new physician or multiple physicians, the physician might not be aware of other medications prescribed for the patient by other physicians. However, a pharmacy might hold all the records of medications that the developmentally disabled patients receive from different physicians, if they go to the same pharmacy. In such instances, pharmacists can provide their expertise with linking multiple diagnoses, detecting drug interactions and answering any health concerns that might have been overlooked unintentionally or due to lack of time during the physician visit.[5]

Pharmacists can assist patient caregivers who aim to provide better quality of life to their clients by (a) teaching them to detect any medication-related adverse events early on, (b) answering medication queries for chronic disease therapy, (c) simplifying complicated medication regimens in layman terms, and (d) training them to improve medication adherence. Patient caregivers in this case aim to understand and work towards the overall well-being of the developmentally disabled patients. By collaborating with these patient caregivers, pharmacists can be provided with valuable information about the success of the medication therapy and medication intake patterns of the patients.[5],[7]

When treating psychiatric disorders related to mood or behavior in developmentally disabled populations, physicians should consider aggression or self-injury as problem behaviors and not psychiatric disorders. In this case, interventions other than medications, preferably behavior therapy, environmental changes, and enhanced communication, are more effective and safer. The use of multiple medications in this patient population may exacerbate their condition or increase the risk of adverse events. The pharmacist should take charge of patients in monitoring and recommending possible medication reductions for patients taking multiple medications. Pharmacists could also assist in ensuring that prescribers start with a lower dose and titrate the dose up slowly when prescribing psychotropic medications, and review these medications at least every 3 months.[5] Primary care providers should work in conjunction with pharmacists to differentiate mental and psychological disorders, determine the time and method of medication intake, treatment for side effects, and the duration of medication therapy.[3]

Pharmacists should keep in mind the social norms and cultural considerations while interacting with developmentally disabled patients who belong to racial minorities. For some minorities, such as African Americans, it is very important to maintain eye contact when listening to or communicating. It might be difficult to establish trust due to general distrust in the health-care system, embarrassment arising from low awareness regarding disease conditions, fear of receiving distressing news about their own health, discriminatory treatment experienced by friends or family and lack of sufficient funds. In addition patients who are very religious may be of the belief that their spiritual faith has more healing power than the use of medications.[8]

Latin Americans who are migrants tend to face linguistic barriers in seeking care.[8],[9] It is important to keep in mind that this group tends to use herbal supplements with their medications and may not understand the significance of disclosing such information to the health-care provider. In addition, they may fear being scolded for using traditional supplements. Minorities such as African Americans and Latinos tend to underutilize services that provide social support since they depend primarily on family members and caregivers for love and support.[8],[9]

As opposed to the Western perception of attaining autonomy and self-reliance for children with developmental disabilities, East Asians, particularly Japanese people, tend to value interdependence, belongingness, and reciprocity while providing care to their developmentally disabled children.[10] Seeking assistance for social or emotional issues, even though visualized as constructive among Caucasians, may seem shameful in the Chinese or Indian culture.[11] Generally, in these cultures, there is reluctance in discussing about disability due to the stigma associated with it and help is sought only when the problems are assumed to be of somatic nature.[12] When Asians fall sick, rather than giving medications, the caregiver in the family provides teas or soups that are traditionally known to restore vitality. Asians believe that imbalances in the body make a person ill and the right diet, instead of strong medications can help the ill person regain his/her strength back.[10]

Proper care coordination and patient pharmacist communication are key to ensuring provision of safe and effective therapy.[4] Treatment of newer symptoms in patients with developmental disabilities does not always require newer medications. Furthermore, pharmacists by assisting physicians in checking medications could help prevent prescriber cascading.

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Conflicts of Interest

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 » References Top

Kalisch LM, Caughy GE, Roughead EE, Gilbert AL. The Prescribing Cascade; 2011. Available from: http://www.australianprescriber.com/magazine/34/6/article/1229.pdf. [Last accessed on 2015 Sep 28].   Back to cited text no. 1
King BH. Psychotropic Medications in Persons with Developmental Disabilities: An Overview for Families and Other Care Providers. Available from: http://www.lanterman.org/uploads/Publication_30977_Psychotropic_Meds.pdf. [Last accessed on 2015 Sep 28].  Back to cited text no. 2
Pauli M, Croslin L. Developmental Disabilities; 2003. Available from: http://www.dds.ca.gov/Publications/docs/healthnotes_developdisabled.pdf. [Last accessed on 2015 Sep 28].   Back to cited text no. 3
Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Bartlett Learning; 2014.  Back to cited text no. 4
Raleigh F, Cohen L, Pauli M. Selected Tips for Counseling Individuals with Developmental Disabilities in Health Notes: Care of Children and Adults with Developmental Disabilities. California Health and Human Services Agency and California State Board of Pharmacy; 2003. p. 39-44. Available from: http://www.dds.ca.gov/Publications/docs/healthnotes_developdisabled.pdf. [Last accessed on 2015 Oct 20].  Back to cited text no. 5
Wallace MD, Dyer EJ, Penrod B. Treatment adherence in developmentally disabled/cognitively impaired patients. In: Promoting Treatment Adherence: A Practical Handbook for Health Care Providers. 1st ed. California: Sage Publications; 2006. p. 415-20.  Back to cited text no. 6
Bradley E. Psychotropic Medication Issues; 2015. Available from: http://www.vkc.mc.vanderbilt.edu/etoolkit/mental-and-behavioral-health/psychotropic-medication-therapy/. [Last accessed on 2015 Sep 28].   Back to cited text no. 7
Gavin JR 3rd, Wright EE Jr. Building cultural competency for improved diabetes care: African Americans and diabetes. J Fam Pract 2007;56 9 Suppl Building:S22-8.  Back to cited text no. 8
Cabellero AE, Tenzer P. Building cultural competency for improved diabetes care: Latino Americans and diabetes. J Fam Pract 2007;56 9 Suppl Building:S7-13.  Back to cited text no. 9
Hsu WC, Yoon HH. Building cultural competency for improved diabetes care: Asian Americans and diabetes. J Fam Pract 2007;56 9 Suppl Building:S15-21.  Back to cited text no. 10
Hsu WC, Yoon HH, Gavin JR 3rd, Wright EE Jr., Cabellero AE, Tenzer P. Building cultural competency for improved diabetes care: Introduction and Overview. J Fam Pract 2007;56 9 Suppl Building:S11-4.  Back to cited text no. 11
Glassheim B. A Guide to Evidence-based Practices for Individual with Developmental Disabilities. Saginaw County Community Mental Health Authority; 2009. Available from: https://www.sccmha.org/quality/A%20Guide%20to%20EvidenceBased%20Practices%20for%20Individuals%20with%20Developmental%20Disabilities%20V%20%201%200.pdf. [Last accessed on 2015 Oct 1].  Back to cited text no. 12

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