How many times have you gone to the doctor and left with several boxes of medication, one to treat the original problem, and another because you were told, “If you get this symptom, take this”? For older people taking several medicines every day, that extra prescription could sometimes be treating a side effect of another drug rather than a new illness.

New research has identified 24 potentially harmful prescribing cascades that could leave older adults taking additional medicines they may not have needed in the first place. For British and other international residents living in Spain, the findings are a reminder to look at the whole medication list when a new symptom appears, rather than assuming every new problem needs another prescription. 

When one medicine leads to another

A prescribing cascade happens when a side effect from one medication is mistaken for a new medical condition. Instead of stopping, changing or reviewing the first medicine, another drug is prescribed to deal with the new symptom. That medicine can then produce another side effect, potentially leading to yet another prescription. The result can be a growing list of medicines without the connection between them being recognised.

The new study, published in the BMJ, examined prescription data covering 2,297,942 community-dwelling adults aged 66 and over in Ontario. Researchers started with 65 potentially inappropriate prescribing cascades previously identified by an international panel of experts, then assessed how frequently the medicines were prescribed and how closely the prescriptions followed one another. Twenty-four met all three criteria used to identify the highest-priority cascades. 

Some of the combinations may look completely unrelated

One of the problems is that the original medicine and the later prescription can appear to have nothing to do with each other. Among the cascades identified as having the highest incidence was iron supplements followed by laxatives, occurring in 11.9 per cent of the relevant prescribing sequences studied. Another involved cholesterol-lowering statins followed by pain medication, while another involved cholinesterase inhibitors followed by sleep medication. 

The researchers also found particularly strong temporal associations between some medicines and subsequent prescriptions. These included corticosteroids followed by antipsychotic medication, laxatives followed by anti-diarrhoeal drugs, and cholinesterase inhibitors followed by anti-nausea medication. 

That does not mean these combinations are always wrong. Some prescribing cascades are deliberate and medically appropriate, particularly where a known side effect is being prevented or treated. The concern is when a drug-related symptom is mistaken for a separate condition and another medicine is added unnecessarily.

When in Spain…

Spain is renowned for not going easy on prescription medication, I for one have come out of consultations with at least 4-5 boxes of medicine just for an allergic reaction or muscle damage. For expats, keeping track of all those medicines can become even more complicated. You may have one prescription from your Spanish GP, another from a private specialist, and medicines that you regularly take from the UK or another country. Add over-the-counter painkillers, antihistamines or supplements and it becomes surprisingly easy for one doctor not to have the complete picture.

That is why it is important to tell every doctor or pharmacist everything you are currently taking, including medicines prescribed by another doctor and products you have brought with you from home. This becomes particularly important if you move between Spain’s public and private healthcare systems, where different doctors may not have access to the same prescribing records.

For those who are not fluent in Spanish, explaining a long medication history can also be difficult, particularly when discussing side effects or explaining when a symptom first appeared. Keeping a current written list of your medicines, their doses and what each one is for can make those conversations much easier, and could help a doctor spot when a new symptom might actually be linked to something you are already taking.

The warning is particularly important for older adults

Older people are more likely to live with several chronic conditions and therefore take multiple medicines at the same time. That increases the possibility that a new symptom will be attributed to another illness rather than a medication side effect. 

The researchers say conversations between patients and healthcare professionals can miss the connection between the first medicine, its side effect and the later prescription. They argue that doctors need to consider why every medication was started and whether it is still necessary when another drug is being considered. 

What should you do if you take several medicines?

Do not stop prescribed medication without speaking to a healthcare professional. Instead, if you develop a new symptom after starting or changing a medicine, ask whether it could be a side effect before simply adding another treatment. Keep an updated list of everything you take and show it to your doctor or pharmacist, including prescription medicines, over-the-counter products and supplements. If you have accumulated several prescriptions over the years, it is also reasonable to ask your doctor or pharmacist to review the complete list with you.

The researchers say better medication reviews and clinical systems that can flag possible prescribing cascades could help prevent unnecessary treatment and reduce medication-related harm.  For anyone living in Spain who has found their medication cupboard gradually filling with more and more boxes, the research offers a simple question worth asking at your next appointment: Could this new medicine be treating a side effect from the last one?

Residents have paid a regional charge meant to modernise Andalucía’s sewage network, yet ageing treatment plants buckled again this summer. Bacteria forced bathing bans across four coastal provinces, and one of Málaga’s best-known beaches is still closed as the region heads into autumn.

Bil Bil beach still closed after the latest E. coli alert

Regional health inspectors closed Bil Bil beach in Benalmádena on Wednesday September 9, after tests found elevated levels of E. coli, a bacteria linked to sewage contamination. Red flags and warning signs went up along the shoreline, and officials said access would stay barred until new samples came back clean.

It was the second closure at the popular Costa del Sol beach in less than a month, after several Benalmádena beaches were shut in August over suspected biological contamination that left some swimmers with skin irritation. Vox’s local spokesperson Joaquín Amann has since called for the resignation of Félix Romero Moreno, president of Acosol, the public company responsible for sewage infrastructure along this stretch of coast, accusing it of years of poor maintenance.

A pattern repeated in Málaga, Cádiz, Huelva and Granada 

Bil Bil is only the most recent entry on a long list. Around a dozen beaches across four Andalusian provinces were temporarily closed to swimmers this summer after tests picked up E. coli and other markers of sewage contamination. 

In Cádiz province, five beaches, including Rota’s Punta Candor and Chipiona’s Micaela, were closed on the same day in late August. Huelva saw warnings at Punta Umbría and Matalascañas, while Granada’s Costa Tropical recorded closures at Salobreña, Almuñécar, Albuñol and Sorvilán. Most bans were lifted within days once fresh tests came back clean, though Bil Bil still remains closed. 

Treatment plants built for a fraction of today’s summer crowds 

Much of the region’s sewage infrastructure dates back more than 20 years, and is not designed for populations that can multiply several times over once the tourist season begins. Some resort towns now see their number of residents rise so much higher in July and August that the strain on treatment plants has become too much and they are unable to cope with it. 

When plants reach capacity, untreated or partially treated wastewater can end up discharged closer to the coastline, which is exactly the scenario health authorities are trying to catch with routine testing before it reaches swimmers.

Málaga’s plants have the worst compliance record of any Andalusian province, with Cádiz and Almería not far ahead of it. Only Córdoba, well inland and away from the tourist coast, clears the required standard comfortably.

Where Andalucía’s €678m water charge for sewage actually went

Every Andalucian water bill includes a regional charge, the canon de mejora de infraestructuras hidráulicas (a fee added to water bills to fund sewage and water infrastructure upgrades), which has raised more than €1.4 billion since it was introduced. Yet Andalucía’s regional auditor, the Cámara de Cuentas, revealed in April that around €678 million collected through the charge had not been invested in the sanitation works it was meant to pay for.

Regional rules have also been changed to let money raised through the same charge be redirected to other repairs, including storm damage, rather than reserved solely for sewage upgrades. Spain has separately been fined more than €84 million since 2018 over towns, including Barbate in Cádiz and Matalascañas in Huelva, whose sewage treatment falls short of EU standards, with the bill expected to approach €100 million by the end of the decade.

How to check before you go for a swim

The regional health department publishes updated reports on bathing water quality for all five coastal provinces roughly every two weeks throughout the summer, available through the Junta de Andalucía’s beach information catalogue. Anyone planning a trip to the coast can check a specific beach’s current status there before setting off.

For Bil Bil, and the handful of other beaches still awaiting the all-clear, that is currently the only way to know whether the water is safe, alongside the visual cues at the beach itself. Red flags and warning signs are still worth watching for on arrival.

For many people living along the coasts, the frustration is less about any single closure and more about the pattern that keeps repeating itself. The same charge keeps appearing on every water bill, and the same warning signs on the same stretches of sand, summer after summer. So, where exactly has the €678 million gone? That’s the big question hanging over Andalucía’s coastline.

A Marbella volunteer network is helping hundreds of vulnerable residents stay connected, with local shops even able to raise the alarm when an elderly customer suddenly stops coming in.

Marbella’s volunteers tackle loneliness

Marbella Voluntaria is continuing its work with older and vulnerable residents after Marbella Town Hall renewed its annual agreement with the association, providing over €40,000 to support its social programmes.

Proyecto Faro is at the heart of the work, currently supporting around 240 people, mainly older residents who live alone without close family nearby. Volunteers do far more than make occasional visits. They can accompany people to medical appointments, hospitals or tests, visit them at home, go for walks together and keep in touch by telephone.

Marbella Voluntaria president Maria del Carmen Bertomeu said volunteers can provide both practical assistance and regular human contact, helping people who might otherwise spend much of their time alone.

Local shops can help spot vulnerable residents

An unusual part of Proyecto Faro involves local businesses in Marbella’s neighbourhoods. Shopkeepers and other traders who know their regular customers can contact Marbella Voluntaria if an older person who normally visits suddenly stops appearing for several days.

That early warning can allow the association and local Social Services to check whether something has happened and whether assistance is needed. For older residents living without nearby relatives, that connection can provide reassurance as well as practical help.

Almost 900 pupils take part in intergenerational project

Marbella Voluntaria is also bringing older people and youngsters together through its intergenerational programmes. Nearly 900 pupils from local schools have taken part in workshops during the past year, giving older residents an opportunity to share their experiences while encouraging children to learn more about ageing, volunteering and social responsibility.

Other activities include social-skills workshops for teenagers temporarily excluded from school and educational sessions designed to help young people understand the challenges faced by older residents.

Weekly workshops led by a volunteer psychologist are also available for older people, while the association organises museum visits, theatre trips, walks and other social activities.

Support goes beyond companionship

Marbella Voluntaria also provides guidance when residents face social or financial difficulties. Help can include information about assistance and discounts linked to essential household supplies, with people referred to other organisations or municipal services when more specialist support is required.

Ten Centros de Participación Activa across the city are also being used for talks and activities designed to explain available resources and encourage older residents to stay involved in community life. Marbella Council’s renewed funding will help the association continue these programmes, but the figures give a clearer picture of their reach: around 240 older people receiving support through Proyecto Faro and almost 900 schoolchildren involved in intergenerational activities.

For Marbella residents who have no close family network nearby, sometimes the most valuable service is simply knowing that somebody will notice if they stop answering the phone or fail to turn up at their usual shop.