Working at a skilled nursing facility offering acute and post-acute care services, and providing long-term care for geriatric and psychiatric patients has exposed me to the Gradual Dose Reduction (GDR) concept. My preceptor provided critical leadership and direction on appropriate patient care in such a setting. Given that the facility cares for elderly residents and psychiatric patients, they typically require prolonged doses, necessitating mandatory tapering when specific clinical outcomes are met. I noted that such tapering attempts require meticulous planning since my preceptor had to organize an interdisciplinary psychotropic medication regimen meeting to iron out concerns on the same issue. Without a doubt, this highlighted my preceptor’s genuine leadership style. As a result, I learned the essential details involved in gradual dose reduction. Therefore, I aim to re-assess my GDR attempts to make later trials at this nursing facility more effective.
Gradual dose reduction (GDR) entails tapering drugs stepwise to determine if conditions, symptoms, or risks can be controlled using a smaller dose or whether it is worthy of discontinuing the medication altogether (CMS, 2017). Such reduction is especially essential for various psychotropic drugs, which are broadly applied at this nursing facility. Although stepwise drug reduction is critical for managing psychiatric patients, I have discovered that it is incredibly challenging during implementation. Therefore, to implement GDR effectively, my preceptor stresses that I need to evaluate patients’ clinical indications and obtain their accurate histories and existing behavioral logs.
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Examining patients’ clinical indications will be necessary to understand the extent of psychotropic drug use, if any. According to CMS (2006), antipsychotics should be employed for the least period, prescribed at the smallest probable dose, and constantly undergo the gradual dose reduction process. However, for some psychiatric disorders such as bipolar disorder or schizophrenia, it would be clinically contraindicated to implement GDR due to the patients’ psychiatric volatility. Therefore, this means that I have to apply a dose minimization process at this facility which recognizes the likelihood of withdrawal symptoms. Besides, I have to structure the GDR to suppress any negative clinical consequences that may arise. A particularly effective GDR uses a two-stage method of 50% reduction in dosage that includes a 1.5 drug half-life adjustment for patients aged between 65 and 89 years and 2.0 half-life change for patients over 90 years (Tjia et al., 2015). In essence, by adopting such a structured drug reduction process based on drug kinetics, I would significantly curb adverse clinical effects on patients in this facility.
Additionally, my preceptor highlighted that getting reliable patient histories is vital to the GDR process. Such accurate records would provide me with dependable patient responses and behaviors that would inform the appropriate instances to commence or halt GDR. For example, I would identify patients with histories of being a risk to themselves to ensure the sustenance of their medications. In addition, I would identify patients with a history of failed drug taper attempts to guarantee that I exercise appropriate care in the current GDR program. As such, accessing reliable patient history would help me attain reliable GDR for this nursing facility’s patients.
References
CMS. (2017). State Operations Manual: Guidance to Surveyors for Long Term Care Facilities . Centers for Medicare and Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf .
CMS. (2006). CMS Manual System. Pub 100-07 State Operations Provider Certification . Centers for Medicare and Medicaid Services. Retrieved 9 May 2021, from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984.html .
Tjia, J., Reidenberg, M. M., Hunnicutt, J. N., Paice, K., Donovan, J. L., Kanaan, A., ... & Lapane, K. L. (2015). Approaches to gradual dose reduction of chronic Off-label antipsychotics used for behavioral and psychological symptoms of dementia. The Consultant Pharmacist® , 30 (10), 599-611. https://doi.org/10.4140/TCP.n.2015.599
