Overcoming Resistance to Gradual Dose Reduction (GDR)

CMS, in its new guidance for long-term care surveyors taking effect on March 24, 2025, specifies practices for Gradual Dose Reduction (GDR) for residents who are receiving psychotropic medications.

In long-term care, research suggests that health professionals may worry about negative patient outcomes associated with GDR—while overlooking the risks and adverse effects of psychotropic drugs. This blog presents insights into resistance and barriers to GDR implementation, along with practices that position facilities for success.

CMS F605 and GDR defined

The revised CMS F605 tag states, “Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.” CMS defines GDR as “the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.”

In nursing home practice, long-term care and policy experts have examined both obstacles and facilitators related to GDR. Here’s what they’ve learned.

GDR: benefits and barriers

Behavior begins with beliefs about GDR. Simmons et al. examined how nursing home staff (primarily nurses) characterize the pros and cons of antipsychotic usage in dementia care:

• Benefits of GDR were described as improvement in quality of life, improvement in family satisfaction, reduction in falls, and regulatory compliance.
• Barriers to GDR were described as family resistance, potential for worsening or return of symptoms or behaviors, lack of effectiveness and/or lack of staff resources to consistently implement nonpharmacological management strategies, risk aversion of staff, and safety concerns.

BPSD and GDR

Professionals may regard antipsychotics and other psychotropic drugs as go-to solutions for managing behavioral expressions of dementia (BPSD), comment Hirdes et al, publishing in JAMDA.  However, the “overall effectiveness” of antipsychotics for this use is “unclear,” they say.

Grounded in a belief that antipsychotics are a solution for BPSD, it’s no surprise that many healthcare professionals hesitate about GDR. They have “concerns that behavioral disturbances will increase with discontinuation,” according to Hirdes et al.  

Reporting on a systematic review, Moth et al. concur, citing “a strong belief” among long-term care health professionals that discontinuing psychotropic drugs could lead to “negative patient-related outcomes”. Hand-in-hand with this belief, practitioners may “downplay” adverse effects of psychotropic medications, the researchers suggest.

The reality is the antipsychotic use in dementia can lead to multiple adverse outcomes and may exacerbate behavioral symptoms, according to some research.

GDR outcomes

In a Cochrane review examining withdrawal versus continuation of long-term antipsychotic drug use for BPSD, van Leeuwen and colleagues conclude that discontinuation of antipsychotics “may make little or no difference to overall neuropsychiatric symptoms”. They also comment that “most behavioral complications of dementia are intermittent and often do not persist for longer than three months.”

For nursing home residents living with dementia and experiencing BPSD, GDR is “challenging,” Moth et al. recognize. Successful deprescribing hinges on understanding that there are “positive patient-related outcomes of doing so,” they observe.

GDR barriers

Barriers to successful GDR can include limited staffing and lack of access to a physician and/or medical specialists who can guide the process; lack of clear guidelines around GDR; communications challenges—with residents, families, and staff; and lack of education (Visser et al.).

GDR: practices that help

Recognizing and removing barriers can go a long way, according to Visser et al. it is important to address beliefs and fears about deprescribing. It’s also important to devote adequate resources and education to support care teams. Visser and colleagues advocate for multidisciplinary collaboration and for patient/family involvement in decision-making.

To help nursing homes succeed with GDR, Hirdes et al. recommend engaging stakeholders around causes and solutions for resident behaviors; implementing a culture of person-centered care; conducting regular medication reviews; instituting clear guidelines; and using reporting and feedback.

Hirdes et al. piloted an antipsychotic reduction intervention model in 45 Canadian nursing homes. Their approach was multifaceted, including education, training, coaching, and reporting, engaging interdisciplinary teams. Not only did they achieve substantial improvements in rates of antipsychotic usage—they found no evidence of worsening behavioral symptoms in the residents they studied.

These researchers point the way forward as long-term care leaders aim for safe and effective approaches to GDR. GuideStar Eldercare uses a six-step treatment approach to address the need for GDR holistically. GDR is a key component of GuideStar Eldercare Long-Term Care Antipsychotic Stewardship®.

Learn more about documenting GDR, and prepare for new CMS guidance with tips from the GuideStar team.