Prescribing cascade in an older adult with bipolar disorder

The prescribing cascade begins when medication side effects are misinterpreted as new symptoms, leading to the addition of new drugs. This case involves a 75-year-old female with a history of Parkinson’s disease, dementia, bipolar disorder, and diabetes. She presented with complaints of bradykinesia, difficulty walking, and inability to move independently. The patient had been on long-term antipsychotic treatment (olanzapine) for bipolar disorder, leading to parkinsonian symptoms, which were mistakenly diagnosed as dementia. Consequently, the patient was prescribed donepezil, an antidementia medication. During this period, she developed depression and urinary incontinence, for which duloxetine and fesoterodine fumarate were added to her treatment. The patient’s functionality and quality of life further deteriorated due to inappropriate medication use and polypharmacy. After evaluation, a decision was made to gradually discontinue several of the patient’s medications, including memantine, fesoterodine fumarate, and donepezil, while reducing the olanzapine dose. Following these adjustments, her mobility improved, appetite increased, and overall condition stabilized. This case highlights the need to closely monitor older adults with mental health problems taking multiple medications for adverse drug reactions. The frequency of monitoring should be individualized according to the patient’s risk factors and treatment response. It also contributes to increased awareness among healthcare professionals and caregivers of the prescribing cascade among these individuals.