Key Guidelines for Gradual Dosage Reductions of Psychotropic Medications

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