Graphical Abstract
Gradual dosage reductions (GDRs) of psychotropic medications are required by federal guidelines in skilled nursing facilities. Equally important is the fact that GDRs are a crucial cornerstone of good clinical and pharmaceutical care. Thorough evaluation of each medication prescribed to residents should be made on a routine basis, with detailed documentation justifying the continued utilization of any medication. This process is especially crucial when medications are being employed outside the typical standards of care. I am often asked, “How does a facility implement a successful graduation dose reduction program?”
Who is a Candidate for GDR of Psychotropic Medication?
Many nursing home residents routinely take multiple medications, many of which have unwanted side effects. In the broadest sense, any resident taking any medication should be considered a candidate for reduction or discontinuation. This optimization process begins with a risk-benefit analysis that explores the question, “How do these risks compare to the potential and perceived benefits of continuing the medication?”
Both perceived and potential benefits should be considered, as it is a common practice to underestimate a medication’s risk and overestimate its benefit. We frequently see how the perception of low risk is reinforced over time and dismissed in phrases such as, “Oh, Mom has taken that Valium for years.” The fallacy of this point of view is that medications never have adverse or unintended effects — until they do.
In the case of benzodiazepines, it might be a fall that results in a fracture. For antipsychotics, there is the risk of falls, tardive dyskinesia, or stroke. Even antidepressants have risks of arrhythmias, hyponatremia, and anticholinergic side effects. The key is to find the balance of efficacy and adverse events, commonly known as the lowest effective dose. This is the intended end goal of the GDR guidelines.
Clinical Considerations
It is important to remember that the body does not care what we prescribe a medication for, what the Food and Drug Administration says about a medication, or whether you intend to use the medication for sleep, depression, appetite, or all three. The body will respond to a medication without regard for any of these wishes.
Over the years I have established a few basic tenets of appropriate psychotropic medication prescribing, but these could easily apply to any medication.
- •Find the low-hanging fruit: look for low doses. An order such as “Quetiapine 25 mg QHS” (every night at bedtime) is a red flag that this medication is being used for sleep. Due to its histamine and alpha blocking activity (think Benadryl + Terazosin), sedation will be produced, but so will a high risk of falls via orthostasis and a decent potential for constipation. This is a common new admission order, and the best practice would be to perform a one- to two-week taper down to discontinuation.
- •Be patient. Many psychotropic medications can take two to four weeks to have an impact, with the full effects kicking in up to two months later. Resist the temptation to consider any changes within those time frames as markers of absolute success or failure. For example, if we try a dose reduction on Monday and the resident has an episode on Tuesday, it’s not the medication’s fault. On the other hand, be careful to declare a medication a success if the symptoms disappear on the third day of treatment. This is more likely related to side effects of the medication — namely, sedation — which they will grow accustomed to over time. Side effects are first, then efficacy.
- •Be realistic. There are no medications that are approved for the treatment of agitation in dementia. Clearly spell out the goals of treatment, and ask, “Is this medication backed by realistic, evidence-based science that supports its use in this resident?” It is more likely that, as above, a side effect of the medication is being used to address a symptom.
- •Be aware of prescribing cascades. The ever-increasing quantity of medications prescribed to our seniors heightens the likelihood of medication-induced disease. This is a situation where a medication is prescribed that has unintended effects, which are determined to be symptoms of a previously untreated or undertreated disease. A new medication is then added, which carries its own side effects and interactions, and the cycle continues.
- •Don’t be afraid of not prescribing. Sometimes there are no pharmaceutical answers to complex clinical questions. Be an advocate for the judicious use of psychotropic medications. Medications should be the last step in any process that is designed to treat behaviors causing distress to the resident or others. Although survey regulations may use the term “nondrug interventions,” its use should be avoided. Instead, focus on naming the actual interventions (e.g., “behavior management plan to reduce hoarding”) and make sure that the interventions are tailored to the particular resident. All residents are unique, so the solutions to what is ailing them should be as well.
- •Have a purpose. Ask the question, “For what specific reason am I prescribing this medication?” Be exact in your rationale, what the treatment goals are, and what clinical outcomes will represent treatment success or failure. For example, “I am prescribing this medication for severe aggression that is causing significant distress to the resident and her fellow residents. I will reevaluate this dose in two to four weeks for evidence of improvement. I will measure improvement by the frequency of physical and verbal aggression to others as reported by the clinical team.”
- •Think of the federal GDR psychotropic regulations as minimal standards. Federal regulations require that a GDR of a psychotropic medication is attempted twice in the first year of admission or initiation of the medication, then annually thereafter. But the timing of GDR attempts should not be limited by these strict rules. Instead, they should be individualized to the specific needs of each resident. In other words, if you think that a particular medication can be lowered, don’t wait until the next required GDR.
- •Be cautious with chronically mentally ill residents. An underlying precept of the GDR process is the reduction or elimination of “unnecessary medications,” especially for dementia patients. For residents with chronic psychotic disorders such as schizophrenia, psychotropic medications are essential. Although we should always evaluate for ways to use the lowest possible effective dose of any medication, for many of these patients a GDR may in fact not be indicated and could be unsafe and destabilizing. When you elect to not reduce dosage for such patients, you must carefully document the reasons why a GDR is contraindicated. A caveat to this would be the 65 years or older resident who is newly diagnosed with schizophrenia, bipolar disease, or other chronic mental illness. Validate their authenticity, not just for the sake of justifying a dose reduction, but for removing a potentially inappropriate diagnosis.
- •Don’t go it alone. Last but certainly not least, recognizing that the entire clinical team is involved in medication optimization is key to developing a successful program. The pharmacist is often tasked with monitoring the progress and timing, identification, planning, and implementation of GDR, but attempts should involve all disciplines. For instance, when dealing specifically with psychotropic medications, treatment outcomes are subjectively measured by the certified nursing assistants in their daily care of the resident. Open-ended questions such as “How is Mrs. Jones doing since admission (or since our last discussion)?” or simply “Tell me about Mrs. Jones” provide a starting point for medication evaluation.
When we work together, our team will often discover subtle changes that may not be explicitly described in the clinical record but may lead to valuable clinical insights. Unpeeling the layers of symptoms and treatments allows the team to make more informed decisions that ultimately lead to better outcomes for our residents.
Dr. Foley has been a consultant pharmacist for Omnicare Central Florida since 1999. He is on the board of directors for FMDA. The opinions expressed herein are entirely his own.
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