Gradual Dose Reductions

Appendix PP of the State Operations Manual defines Gradual Dose Reduction (GDR) as the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.

Why Should Medications be Gradually Reduced

Psychotropic medications should be tapered to determine if continued therapy is still beneficial to the resident, or to help find the optimal therapeutic dose. Tapering may be appropriate if the resident’s original target symptoms have resolved, non-pharmacological approaches have been effective, or if the resident’s clinical condition has improved or stabilized. The effectiveness of psychotropic medications should be evaluated during each prescriber assessment, consultant pharmacist MRR, and during the quarterly MDS review.

When to Gradually Reduce

Antipsychotic and psychopharmacological (anxiolytic, antidepressant, anticonvulsant) medications should undergo GDR within the first year of the resident being admitted on the medication or after the prescribing practitioner has initiated the medication.  The facility must attempt a GDR in two separate quarters with at least one month between the attempts, unless clinically contraindicated. A GDR must be attempted annually thereafter, unless clinically contraindicated.  Sedatives should undergo GDR every 3 months.

Clinical Rationale

A prescriber response is required for GDR recommendations.  If the prescriber refuses the recommendation, clinical rationale for declining the attempted dose reduction is needed.  GDR recommendations that are refused and do not have a clinical rationale, are considered to be an unnecessary medication.