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Step Up Your GDR Game Part 2: Implementation Strategies

Part 1 of this two-part series on conducting gradual dose reductions (GDRs) for residents receiving antipsychotic and other psychotropic medications focused on team-building and participation. In Part 2, Maureen Kelly, RN, BSN, NHA, a senior clinical consultant for LW Consulting in Harrisburg, PA, suggests strategies that directors of nursing services (DNSs) can use to identify GDR candidates and improve the antipsychotic/psychotropic team’s success rate based on the antipsychotic reduction efforts she led as the DNS for a 33-bed facility:


Don’t make assumptions about a resident’s GDR potential


It’s easy for busy clinicians to assume that a GDR isn’t clinically indicated for certain residents based on diagnoses and other information in the medical record, says Kelly. “However, when you dig deeper, often you learn that you can’t really determine when or if a GDR was ever attempted. So, it’s important to take a fresh look at all of your residents. Your medical director should be able to help with this assessment.”


Note: Need assistance identifying which residents should have GDRs first? Try this Antipsychotic Reduction Resident Prioritization Tool from the QIO Telligen.


Develop criteria for medication use


“The No. 1 question to ask when discussing a potential GDR is: Will the GDR improve the resident’s symptoms and functioning to restore optimal quality of life and ADL functioning?” says Kelly. “However, it’s also important to develop criteria for when antipsychotic and other psychotropic medications will be considered.”


For example, in Kelly’s facility, a diagnosis alone did not warrant the use of antipsychotic medications, she stressed. “Residents who were admitted to our facility on antipsychotics, regardless of having a diagnosis of dementia, were evaluated individually by the physician in collaboration with the interdisciplinary team (IDT), which included the behavioral health team and the resident’s family. The physician considered antipsychotic medications for residents with dementia, but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms were identified and addressed.”


Kelly and her team established the following criteria for antipsychotic medication use and then conducted a root-cause analysis of behavioral symptoms to determine whether these criteria had been met:



Antipsychotics could be appropriate when …


· Behavioral symptoms present a danger to the resident or others.


· Behavioral symptoms are not due to a medical condition or problem that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued—and those symptoms are persistent or likely to reoccur without continued treatment. Examples of medical conditions or problems that could be anticipated to improve or resolve include:

o Headache or joint pain

o Fluid or electrolyte imbalance

o Pneumonia

o Hypoxia

o Unrecognized hearing or visual impairment

o Medication side effect

o Polypharmacy


· Behaviors are not sufficiently relieved by nonpharmacological interventions and are not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety. Examples of environmental stressors include:

o Alteration in the resident’s customary location or daily routine

o Unfamiliar care provider

o Hunger or thirst

o Excessive noise for that individual

o Inadequate or inappropriate staff response

o Physical barrier


· Behaviors aren’t due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to the resident’s cognitive impairment (e.g., the mistaken belief that this is not where they live or the inability to find their clothes or glasses) that can be expected to improve or resolve as the situation is addressed.


Antipsychotics shouldn’t be considered when …


· The only symptoms are one or more of the following, which often aren’t amenable to treatment with antipsychotic medications:

o Wandering

o Poor self-care, including inappropriate dressing/undressing

o Restlessness

o Impaired memory

o Mild anxiety

o Insomnia

o Inattention or indifference to surroundings

o Sadness or crying alone that is not related to depression or other psychiatric disorders

o Fidgeting, including tugging at clothing

o Nervousness

o Uncooperativeness

o Vocally disruptivebehavior

o Inappropriate urination/defecation

o Hiding and hoarding

o Eating inedibleobjects

o Repetitiveactivity

o Pushing wheelchair-boundresidents

Get to know your residents


“All behaviors have meaning. Residents with dementia often are attempting to respond to their current situation and communicate their unmet needs,” says Kelly. “For example, a resident living with dementia who continually repeats the same question over and over may be feeling insecure or unsafe, or upset about not being able to engage meaningfully in their environment. A non-drug treatment approach to this resident could include setting up a structured routine, providing reassurance (verbally or through touch), and engaging the resident in activities that match their interests and abilities.”


When it comes to dementia, behavior symptoms are much easier to work with when the team better understands the person behind the illness, says Kelly. “Get to know the residents you care for. Some problems that should be very simple to solve become incredibly complicated due to the failure to remember that dementia is a 24-hour-a-day condition, as well as a lack of communication.”


Create a toolbox of non-drug approaches


Nonpharmacological interventions and behavior management strategies should be person-centered and tailored to the individual, such as adapting or adjusting the environment to minimize identified stressors, says Kelly. “Interventions also should be guided by the resident’s background; likes and dislikes; religious, cultural, and life experiences; and other resident-specific factors. In addition, your team should use standardized behavioral assessment tools to determine the effectiveness of psychosocial interventions.”


Kelly offer the following ideas for specific nonpharmacological interventions to put in the IDT’s arsenal:



· Massage and touch

· Individualized music

· Controlledmultisensory therapy

· Stimulation

· Arttherapy

· Aromatherapy


Social Contact: Real orSimulated

· Pet therapy

· Simulated interactions, including family videos

· 1:1 socialinteraction

· Holding babies


Behavior Therapy

· Differentialreinforcement

· Stimuluscontrol



· Recreational activities

· Outdoorwalks and other physicalactivities

· Folding laundry

· Setting the dining room table


Environmental Modifications

· Natural wandering areas

· Enhanced environments

· Reducedstimulation

· Light therapy

· Classical or tranquil music

· Baking/the aroma of home-cooked food


Note: Also see “Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia” from the 2018 Alzheimer’s Association Dementia Care Practice Recommendations published in The Gerontologist (Volume 58, Issue suppl_1), as well as the TMF Health Quality Institute’s three-page Antipsychotic Alternatives tip sheet.


Involve the families


“If the family attends the care conferences, your team can discuss the GDR with them there. However, if the family doesn’t attend the care conferences, have your social worker call them and explain what you will be doing,” says Kelly. “You want to be sure that you’ve communicated your plans for the GDR to the family so they’re in agreement. In addition, family members may be able to provide valuable information about what the resident liked to do at home (e.g., listen to classical music) so you can develop more unique, individualized interventions.”


Give the physician team input about GDRs


“DNSs shouldn’t allow the consulting pharmacist or a clinician such as a psychiatric nurse practitioner to dictate the facility’s GDR recommendation from their consultation because it typically doesn’t provide the physician with enough information to make an accurate decision,” says Kelly.


“When I’ve spoken to physicians and asked, ‘Why don’t you agree with this GDR recommendation?’ the most common response was, ‘Well, I don’t know why you want to do this. The resident hasn’t been having any problems,’” she explains. “You have to give the physicians the information they need to make an accurate assessment and decide whether they do agree or don’t agree.”


Kelly’s team handled this by including space on the consulting pharmacist’s GDR recommendation form for supporting interdisciplinary documentation. “The social worker and the RN unit manager on the antipsychotics team would write summaries for the physician to read that supported why our team felt that a GDR would be good for the resident.”


Document, document, document


All too often, facilities do GDRs without identifying the GDR, the behaviors, or the nonpharmacological interventions on the care plan, says Kelly. This could be a considerable problem during the Long-Term Care Survey Process (LTCSP). In the “Pharmacy Services” training video developed by the Centers for Medicare & Medicaid Services (CMS) to prepare surveyors for the LTCSP, CMS officials noted that the general revisions to the Appendix PP guidance in the State Operations Manual for both F757 (Drug Regimen Is Free From Unnecessary Drugs) and F758 (Free From Unnecessary Psychotropic Medications/PRN Use) include “using more person-centered language, such as expressions or indications of distress and nonpharmacological approaches to care, and emphasizing documentation to show appropriate use and adequate monitoring of medications.”


“So every time you do a gradual dose reduction, always make sure there is documentation in your nursing notes and on the care plan,” says Kelly. “The care plan must always be addressed, so when you have a GDR, you write the date, the causes of behaviors/symptoms, and your interventions.”


The antipsychotic/psychotropic team should revisit the care-planned GDR at a minimum monthly, recommends Kelly. “However, the best practice is also to review care plans with changes in condition, as well as in conjunction with MDS assessments. You will make some documentation regarding whether the GDR worked and any changes you make to the interventions in response to the resident’s changing goals, preferences, and needs.”


If the resident comes off the medication per the physician’s documented authorization that the medication should be discontinued or that the condition is resolved, the team also needs to resolve that care plan, she adds. Note: CMS confirmed the need to for the IDT to review and potentially revise the comprehensive care plan after each MDS assessment in Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training.


In addition, keeping the care plan up-to-date increases the likelihood of a successful GDR, points out Kelly. “Making just one discipline responsible for all of the nonpharmacological interventions doesn’t serve the resident well. If you do a GDR, everyone from nursing to activities to dietary must be aware of the GDR and the interventions they will need to provide to meet the resident’s needs, and that requires an updated care plan.”


Use your QAPI process


All antipsychotic and other psychotropic medications should be reviewed within the facility’s QAPI (quality assurance and performance improvement) program, suggests Kelly. “Develop a tool or questionnaire that meets your facility’s specific needs. You will want to include questions such as, ‘Is there ongoing monitoring/documentation of the resident’s responses to the unique, individualized interventions the team put into place?” and ‘Are assigned CNAs questioned about what possible causes or triggers may be contributing to the behaviors?’”

Reviewed and revised 3/4/21