Pharmacoepidemiology
Incidence of potential prescribing cascades involving overactive bladder medications among US older nursing home residents Lexie R. Grove* Lexie Grove Grove Grove Grove Grove Grove Grove Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health
Background: Medications for overactive bladder (OAB) can cause severe adverse events among older nursing home (NH) residents, including cognitive impairment and injurious falls. Prescribing cascades, wherein side effects caused by one drug are managed by prescription of a second drug, may contribute to unnecessary OAB drug use. A recent expert panel identified four potentially inappropriate prescribing cascades involving OAB drugs, but little is known about the epidemiology of these cascades in the NH setting.
Objective: To estimate the 90-day incidence of potential OAB prescribing cascade events, defined as OAB drug initiation after initiation of a loop diuretic (LD), cholinesterase inhibitor (ChEI), selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI), or tricyclic antidepressant (TCA), among older NH residents.
Methods: We used 2013-2023 Medicare claims linked to Minimum Dataset clinical assessments to identify long-stay NH residents aged 66 or older with 12 prior months of continuous enrollment in Medicare Parts A, B, and D. The study index date was the first dispensing date (i.e., initiation) of a precipitant drug (i.e., a LD, ChEI, SSRI/SNRI, or TCA). We excluded individuals with any use of a precipitant drug (separately for each drug class) or OAB drug in the 180 days prior to the index date.
Results: We identified 108,249 LD initiators; n=37,100 ChEI initiators; n=95,379 SSRI/SNRI initiators; and n=7,685 TCA initiators (mean age=83 years [SD=8]; 70% female). The 90-day incidence of OAB drug initiation was 0.55% (LD), 0.73% (ChEI), 0.70% (SSRI/SNRI), and 1.16% (TCA). The median time to OAB drug initiation was between 30 and 40 days for all precipitant drug classes.
Conclusions: OAB drug prescribing cascades appear to be uncommon among older NH residents. Clinicians may rely on non-pharmacological strategies to manage urinary symptoms that arise after initiation of drugs known to cause these side effects.