GRADUAL DOSE REDUCTION (GDR) CONCERNS IN GERIATRIC PATIENT WITH MENTAL HEALTH DISORDERS, LIVING IN LONG TERM CARE FACILITIES

Abstract

Introduction Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Update of OBRA guidelines have even farther increased some dosing restrictions, however documentation of necessity and periodic trials of medication withdrawal (GDR) are still emphasized. Almost 20% of American age 55 and older are suffering from some type of mental health disorders which include but not limited to mood disorders (Unipolar/Bipolar), psychosis, anxiety as well as symptomatic management of agitated patients due to other medical condition. Mental health disorders are implicated as a factor for suicide. Men aged 85?years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages. While other treatment modalities (psychotherapy etc.) are implemented most of the time one or more psychotropic medication are used for management of these patient's population. In 2006 Center for Medicare and Medicaid Services (CMS) published guidelines about antipsychotic drug therapy only for specific condition, prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR). There is significant literatures on guidelines and recommendation of GDR in geriatric patients. However, there is limited research and publications on prohibiting or avoiding GDR in some circumstances. We are presenting a case of a patient suffering from mental health disorder comorbid with other medical condition whose GDR might have been the cause of her symptom relapse and the need for acute inpatient management. Methods Ms. GM is 70?years old female with psychiatric diagnosis of schizoaffective disorder bipolar type has been admitted to VA Community Living Center (CLC), after she is medically diagnosed with stage III endometrial cancer and CVA for palliative chemotherapy. She was managed initially with Risperidone 5mg in the morning and 3mg at night, Haloperidol 2mg in the morning and 1mg at night, Gabapentin 200mg twice daily, under the GDR protocol her medication was decreased to Risperidone 2mg twice daily and stop the Haldol all together. Her response were monitored and documented on Computerized Patient Record System (CPRS). While she was initially stable with GDR, gradually she developed hypomanic sxs of paranoid ideation, irritability with hypersexuality as well as expansive thought, disorganized behavior. Ms. GM was not responding to initial behavioral intervention which rendered to an acute inpatient admission for management of her symptom. Once stabilized in the acute inpatient setting, Ms. GM was re-admitted to CLC for continuation of her palliative care of her endometrial cancer, CVA and schizoaffective disorder. Her current psychotropic medication is Risperidone 2mg in the morning and 3mg at night, Gabapentin 300mg QHS, she is responding to the current psychiatric intervention with minimal residual depressive symptoms still remaining. In the last visit her affect improved and she is no longer on one-one observation of irregular behavior. Results Consideration for the exceptions can be as part of GDR for some patient with mental health problem. With proper documentation of patient's response to GDR, utilizing clinical expertise and medication side effects will help prevent relapse of symptoms. Conclusions The goal of recommending psychotropic medication in patients 50 and older is to address mental health disorder and provide quality of life to patients suffering from mental health disorders with or without other medical comorbidities. With respect to their side effects and to avoid polypharmacy, CMS recommended guideline of GDR is an optimal consideration to most of psychiatric patients. However, applying these guidelines are challenging and complex, which requires knowledge of existing clinical evidence, standard of practice on using psychotropic medication with appropriate professional rational on attempting to reduce its dosage. This research was funded by: Zero funding