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Medications constitute an important part of the long-term care provided to residents in nursing homes. Drugs are administered to treat illnesses, arrest or slow down diseases, reduce or eliminate symptoms, or prevent infections. Accurate selection and a dosage step-down strategy can reduce symptom exacerbations and achieve better patient outcomes after a gradual dose reduction (GDR) exercise (Tijia et al., 2015). The administration of medications or combination therapy without proper indications, in high dose levels, for an extended period, or without sufficient monitoring may expose residents to harmful drug interactions, depressive symptoms, and disarray (Center for Medicare and Medicaid Services [CMS], 2016). For these reasons, a systematic dosage step-down is required to achieve optimal patient outcomes.
Gradual Dose Reduction
The CMS (2016) has issued guidelines for correct dosage and specific therapeutic periods for particular drugs. The agency suggests a systematic tapering approach strategy for residents receiving certain classes of medications to determine an optimal dosage level (Tijia et al., 2015). GDR aims to formulate an effective minimum dose that would give the desired results. According to Manzi and Brandt (2017), GDR is indicated in three instances: when a patient has shown remarkable improvement in key health indicators, the disease has gone into remission, the symptoms have abated, and cognitive behavior therapy seems to be working. Treatment outcomes can be determined by evaluating a resident’s physical and social health to deduce if there is a need to stop, step down, or change the drug. The assessment may be conducted after four weeks or six months to determine the efficacy of the medication or dose (Tijia et al., 2015). Occasionally, there may be a need for continued medication, e.g., where a resident has depressive disorders for which he/she must take antipsychotic drugs.
Often, the decision to enroll a patient in a prolonged pharmacotherapy plan depends on tapering the dose to ensure improved patient outcomes at optimal doses (Tijia et al., 2015). The determination of how long a tapering attempt should last depends on the other medications a resident is receiving, disease pathophysiology, individual predispositions to comorbid conditions, and drug pharmacodynamics (Manzi & Brandt, 2017). For instance, some antidepressants, sedatives, and opioid analgesics require a stepwise GDR method to manage adverse events associated with drug dependence.
Use of Psychoactive Medication
The recommended antipsychotic medication must be administered at the lowest dosage for the shortest period and is subject to the GDR requirements. Unless clinically contraindicated, GDR of the neuroleptic drug and behavioral interventions are conducted under close supervision in an attempt to discontinue the medication (Manzi & Brandt, 2017). According to the CMS (2016), within the first year of admission into antipsychotic therapy, a care home should offer two tapering activities in the first and second quarter timed four weeks apart. In subsequent years, one tapering exercise is recommended per annum for residents without co-occurring conditions. If the GDR causes adverse effects on patients and it is discontinued, this decision should be documented and related rationales included in the clinical record (CMS, 2016).
For residents receiving psychoactive agents to control depressive symptoms, including those with schizoid, bipolar disorder, or psychotic conditions, tapering is not recommended for two reasons. First, CMS (2016) suggests that patients with symptom exacerbations should not receive GDR. Second, pharmacological therapy may also be terminated if there is clinical evidence that further GDR would hamper the resident’s functional capacity and outcomes (CMS, 2016).
Medications Requiring GDR in Nursing Facilities
GDR applies to three classes of psychopharmacological drugs: anxiolytics, anticonvulsants, and antidepressants. However, a tapering attempt for these medications is dependent on the condition diagnosed in a resident. Indications that involve GDR include treatments used to manage behavior, stabilize moods, or treat psychiatric disorders (Manzi & Brandt, 2017). Tapering exemptions include when neuromuscular syndromes are co-occurring or when long-acting benzodiazepines are administered to withdraw a patient from short-acting anxiolytics.
Other applicable medications for GDR include any sedative and hypnotic that are used to manage insomnia, such as chloral hydrate, sedating antihistamines, etc. (Manzi & Brandt, 2017). Tapering may also be used for antipsychotics (first- and second-generation agents). Applicable indications are schizophrenia, delusional disorder, mood disorders, and psychotic symptoms, among others. Concerning frequency, the CMS (2016) recommends two GDR exercises conducted a month apart in year 1 of psychopharmacological intervention. In subsequent years, tapering should be done once annually. It is contraindicated when there is a clinical rationale or when symptoms exacerbate following a GDR attempt (Manzi & Brandt, 2017). The tapering frequency for sedatives/hypnotics and antipsychotic drugs is quarterly (three months) and twice annually with a one-month duration between attempts and once in subsequent years, respectively (CMS, 2016).
CMS guidelines for GDR for residents in a nursing facility specify the applicable medications, indications, clinical contraindications, and frequency. Tapering is meant to reduce the risk of sentinel events and improve the clinical outcomes of residents receiving long-term care. Providers are required to follow the CMS recommendations to avoid possible sentinel events related to a drug overdose.
Center for Medicare and Medicaid Services [CMS]. (2016). State operations manual (SOM) surveyor guidance revisions related to psychosocial harm in nursing homes. Web.
Manzi, J., & Brandt, N. (2017). Implications of the final rule on psychotropic medication use. Web.
Tijia, 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. Consultant Pharmacist, 30(10), 599-611. Web.