By Dr. Kenneth L. Scott Jr., DO, CMD
The term “gradual dose reduction” (GDR) is one commonly used in the skilled nursing environment. It refers to the stepwise tapering of a dose to best diagnose whether a patient’s symptoms or risks can be adequately managed through a lower dose or even if the medication can be eliminated.
In theory, GDR is a worthy objective. Weaning a patient off medication over a period is certainly an ideal treatment endgame. In practice, however, it’s a much more multifaceted decision-making process, one that will work for some patients but be detrimental to the health of others.
Let’s take a closer look at one of my recent patients to see how he reacted to an attempt at gradually reducing his medication dosages.
A Personal Study
When John first arrived at our facility for long-term care, I questioned why he should be admitted. He was alert, oriented, and, unlike about half of our patients, had no diagnosis of dementia. An old Army veteran, John presented in a wheelchair with a history of multiple falls. He was no longer able to walk. The scars on both knees revealed past surgical procedures that, according to John, were unsuccessful and left him with severe chronic pain that prevented him from ambulating.
I queried why he had not gone back to the orthopedics department to discuss his pain and whether or not further procedures might improve his ability to be independent. He assured me that he had and stated that he was not going to have further surgery on either knee as he was content to live out the rest of his life in a wheelchair.
John had no family available to help him and, having failed to be able to care for himself, was happy to be admitted to our facility and receive the help he needed to meet his basic needs. He felt the pain medication regimen he was already on was working well for him, and he was satisfied with a plan that included anti-inflammatory medications supplemented with both long-acting and short-acting narcotics. Like most patients on chronic narcotics, John was emphatic about the need to continue these medications and his inability to cope with life without the relief that these medications afforded him.
There was no doubt he exhibited some worrisome signs of opioid use disorder. Furthermore, within a short period of time at our facility, it became clear that his personality was not going to mesh well with many of the other residents. He had a rather short fuse and a sarcastic bite to his dialog that affected both residents and staff alike.
Early on, John required a lot of time and attention, not only from me, as his physician, but from the interdepartmental team as well. It became clear to me that he was depressed, and an antidepressant was initiated. Multiple nonpharmacological interventions were also discussed and put in place. Eventually, John settled into a routine at our facility, and, slowly but surely, his mood improved, and he seemed more content.
I was surprised six months later when, on a routine visit, John mentioned to me that he wanted to consider tapering his narcotics. He had begun an exercise program with direction from therapy that seemed to be helping. Though he was not bearing weight on his legs, the exercise seemed to be helping with the stabilization of his mood.
While small at first, I welcomed even one dose per day in the reduction of oxycodone. Several months later, when he agreed to half the dose of MS Contin, I was again surprised but happy to accommodate his request. He tolerated the reduction in morphine well and reported that he could tolerate the pain and was enjoying his routine.
A Reduction Too Far
Several months later, John came up for discussion in our monthly gradual dose reduction staff meeting, during which we discuss patients individually and whether they are viable candidates for reduced medications. Per federal regulations, it was time to consider John’s dose of antidepressant for gradual dose reduction. He was doing well, so I was concerned about reducing his dose. But he had now gone about six months without any sign of depression, and it was hard to argue that we shouldn’t at least try trimming his dose back a bit. The GDR was ordered, and John tolerated the cutback well. I was happy with the result, and John seemed to be happy as well.
Several more months passed, and John came up for discussion in our meeting again. The next dose reduction stage would be to stop his antidepressant altogether. I was concerned about doing so, but with no evidence of ongoing depression and complete stabilization of mood over the past year, it was again hard to argue against another reduction. Reluctantly, I agreed to discontinue the medication.
It only took about two weeks before signs of John’s earlier discontent and agitation began to return. He again became more sarcastic and, at times, angry. He once again had difficulties socializing with other residents and communicating appropriately with staff. He realized the change in himself and asked that the antidepressant be restarted.
I prescribed the medication, which began to help, but not before John was demanding a return to the former doses of narcotics to control his pain. He reported that his pain had worsened to the point where he was having difficulty sleeping at night and that he could not get comfortable in bed. He was having difficulty coping with the pain. His normal routine, including the exercise program, was being threatened by his worsening condition.
Significant Pressure for GDR
The gradual dose reduction program is part of state and federal guidelines to ensure that residents in post-acute and long-term care facilities are free from unnecessary drugs and monitored to promote or maintain “the resident’s highest practicable mental, physical, and psychosocial well being” (p. 708 The Long-Term Care Survey.).
Like most guidelines, policies, and procedures established in health care, these suggested “rules” are developed to remind health care practitioners of what we should be thinking about in the routine course of patient care. These guidelines are constructed around the concept of promoting the best outcomes for the greatest number of patients. This particular guideline states that “within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a gradual dose reduction in two separate quarters (with at least one month between the attempts).”
Based on this directive, most facilities have a GDR team (which is very similar to the interdisciplinary team) to discuss patients who are on psychotropic medications. Most teams meet monthly, and all patients on psychotropic medication are reviewed. If a patient falls into the time frame of needing a GDR, a discussion should follow concerning the patient’s behaviors, comfort level, ability to function and socialize, and overall well-being.
Unless the patient has not yet been stabilized, the decision is usually made to try a GDR. This is where a physician who in tune with their patient can be of great help.
F-Tag 758 states that the facility “must attempt a GDR . . . unless clinically contraindicated.” The guidelines go on to state that a GDR can be considered clinically contraindicated if
the resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.
The interdepartmental team is usually excellent at reviewing prescribing timelines and ensuring that a resident is discussed in a timely manner. They can provide good insight into the patient’s behavior and performance within the facility. But the clinician’s input is needed when determining the wisdom of whether or not to attempt a GDR.
It is easy to determine when a patient’s symptoms return and the dose needs to be increased or the medication restarted to achieve the desired patient comfort levels. However, the rationale for why additional attempted dose reductions at that time would be likely to impair the resident’s function or increase their distressed behavior is more difficult to determine without an in-depth understanding of the patient in question. Interdepartmental teams are looking to the clinician to guide them in these complex decisions.
It is well established that, for patients with chronic pain, their pain is worsened if they are also depressed. Anger is also known to worsen pain in some individuals. In John’s case, I could have made an argument for not stopping the antidepressant and recommending that we leave him on the lowest possible dose, which he was tolerating well and was helping to stabilize his mood while allowing him to cope with lower doses of narcotics. Because the dose was so small, it made sense to test him off of the medication altogether. This also would reduce the chance of a medication error by removing one additional pill that had to be delivered and simplifying his drug regimen.
Also, it should not go unnoticed that there is significant pressure to reduce medications—especially when considering psychotropics in the nursing home setting. It is more likely that for a patient in the community, the antidepressant would have been left alone altogether since it was working so well and the dose was low to begin with.
As a result of stopping the antidepressant, however, John’s symptoms worsened. He had to restart taking the antidepressant to regain control, and the dose had to be increased. Furthermore, to get back on track, his narcotics were increased to former levels.
With all that in mind, the argument could be made that the GDR program was harmful for John.
The Case for Full-Time Physicians
Not all decisions in medicine are straightforward. Policies, while put in place to ensure the greatest good for most patients, need to be understood and applied in the light of a physician’s understanding of their patient and the greatest good for the individual.
In the past (and often in the present), when doctors are absent from the nursing home environment, they rely almost completely on the word of the nurses in determining what course of action to take in meeting a patient’s needs. This has resulted in patients with severe behaviors being placed on antipsychotics to help control their agitation. When patients become somnolent, they may be easier to deal with. However, some become oversedated, have reduced appetite, lose weight, and develop bed sores or pneumonia.
Although not the intended outcome by the facility or staff, the changes occur gradually and may not be readily perceived with ongoing nursing shift changes and different nurses’ initial point of observation. Several weeks later, when the doctor shows up once again, the concern about the change of function will be raised for the first time.
Although policies like gradual dose reduction are meant to help raise awareness and prevent such outcomes, the doctor’s role is to apply these rules to the individual patient, make the best decision possible, and educate the team regarding the reasons for any change in medication. The note in the chart should reflect this plan.
These are yet more reasons why SilverSage Management Services advocates so strongly for nursing homes and skilled nursing facilities to employ a full-time doctor on staff rather than physicians serving as certified medical directors who only visit a facility a couple of times per month. Having a full-time doctor on staff allows facilities to maintain daily interaction with patients and their conditions. Not only do families want doctors at their loved ones’ bedsides, but the presence of full-time physicians helps build a trust factor with nursing staff and patients alike.
No matter what decision is made in discussion with the team, it may not always be the right one. However, it should be made carefully, and patients should be monitored closely so that further adjustments can be made in a timely manner. In John’s case, his mood is already better. Now, we can start working on those narcotics again.
Dr. Kenneth L. Scott Jr., DO, CMD, is a proud father, husband, and experienced medical professional with over 30 years of experience. From serving in management as a certified medical director to belonging to numerous medical societies, he leads with a vision to change medicine for the better.