Gradual Dose Reduction of Psychotropic Medications
in the Skilled Nursing Setting

By Jessica Badichek, PharmD
Director of Drug Information

Gradual dose reduction (GDR) is a term used often in the skilled nursing setting. In the past, GDR has only been required for antipsychotic medications, however, changes implemented in 2017, require GDR for all psychotropic medications. This involves the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether.1 GDR attempts are required to be made on any psychotropic medication, this includes, antipsychotics, hypnotics/sedatives, antidepressants and anxiolytics.

MediTelecare clinicians are trained to meet CMS gradual dose reduction requirements and follow a specific protocol in our standard operating procedures. In addition, our clinicians utilize a prescribing formulary containing evidence-based recommendations based on clinical diagnosis. This ensures that GDR attempts are being completed properly and are documented in the resident’s medical record.

GDR is especially important in geriatric residents that are at a higher risk for adverse side effects associated with psychotropic medications. Often, newly admitted residents coming from a hospital setting may be on antipsychotics or other psychotropic medications that are no longer indicated after an acute stay. As soon as a resident is put on MediTelecare’s caseload, our clinicians evaluate the resident’s medications and assess for clinical indications that would necessitate psychotropic medication use.

GDR may not always be clinically indicated. CMS states, “Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.”1 CMS also acknowledgesinstances where a lifelong need for medications may be necessary. For example, a resident with schizophrenia may not be able to discontinue an antipsychotic due to risk of psychiatric instability. GDR may be clinically contraindicated in this case and this would be documented in the resident’s medical record by the MediTelecare clinician.

Successful GDR depends on the clinician being able to obtain an accurate history of the resident and current behavioral logs from skilled nursing staff. MediTelecare clinicians use all of this information to adequately assess when to start a GDR process or when to stop GDR due to an increase in symptoms or behaviors.

Gradual dose reduction is a key element of care for MediTelecare clinicians. Whenever possible, our clinicians are looking to discontinue unnecessary medications to reduce adverse effects and lead to better outcomes for the resident.

We encourage our skilled nursing home partners to reach out to us anytime regarding GDR practices and psychotropic medication use in your facility.

  1. Centers for Medicare and Medicaid Services. State Operations Manual: Guidance to Surveyors for Long Term Care Facilities. Available from:

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