Objective: To better understand the impact of gradual dose reduction (GDR) on patients with movement disorders living in long-term care facilities (LCTFs).

Background: More than 2 million Americans live in LCTFs[1]. Medicines for psychological and behavioral symptoms have historically been overused in this setting.[2] In response, the federal Centers for Medicare and Medicaid Services (CMS) instituted requirements for GDR of certain medicines in LTCFs.[3] While GDR protects patients, its broad application may also negatively impact patients with movement disorders complicated by psychosis or pseudobulbar affect. For example, of the 7-10 million people with Parkinson’s disease (PD), more than half develop PD psychosis.[4, 5] While U.S. Food and Drug Administration-indicated treatments are now available for PD psychosis and PBA, GDR could restrict patients’ access.

Method: Literature review.

Results: Federal regulations define a psychotropic drug as one “that affects brain activities associated with mental processes and behavior.”[6] This includes drugs in the anti-psychotic, antidepressant, antianxiety, and sedative-hypnotic classes. Central nervous system (CNS) agents can also be considered psychotropics.[7] The only government approved medicine for PBA—dextromethorphan/quinidine—is a CNS agent and pimavanserin—for PD psychosis—is an antipsychotic, so both are subject to GDR. Both have only one approved dosage, so there is no dose to “reduce” to.

Conclusion: It is essential to end overuse and misuse of medicines in LTCFs, yet subjecting all patients who take approved medicines as indicated to GDR is inappropriate. As currently implemented, mandatory government regulations such as these place an insurmountable barrier between patients and their physician-prescribed medication. Solutions to ensure patients have appropriate access include: 1. The federal government should create a GDR exemption for these two medicines or 2. The federal government should issue guidance noting GDR is inappropriate for these medications. Both approaches, and future efforts to avoid one-size-fits-all GDR policy, ensure that patients’ course of care is appropriate and individualized, not dictated by generic government regulations.

References: References: 1. Department of Health and Human Services. Office of the Inspector General. Medicare atypical antipsychotic drug claims for elderly nursing home residents. May 2011. OEI-07- 08-00150. Available at: http://oig.hhs.gov/oei/reports/oei-07- 08-00150.pdf 2. Hersch EC, Falzgraf S. Management of the behavioral and psychological symptoms of dementia. Clin Interv Aging. 2007;2(4): 611-621. 3. National Partnership to Improve Dementia Care in Nursing Homes & Quality Assurance and Performance Improvement (QAPI). Available at: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2016-12-06-Slide-Presentation.pdf 4. Parkinson’s Association of the Carolinas. Statistics on Parkinson’s Disease. Available at: https://www.parkinsonassociation.org/facts-about-parkinsons-disease/ 5. A 12-year population-based study of psychosis in Parkinson disease. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20697051 6. CMS Medicare and Medicaid Programs; Reform of Requirements for Long Term Care Facilities Final Rule. Vol. 81. Fed. Reg. October 4, 2016. 7. Consonus Healthcare. CMS regulatory changes limit the use of PNM psychotropic medications. Available from: http://www.consonushealth.com/wp-content/uploads/2017/09/CS_Newsletter_Article.pdf?x95358

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MDS Abstracts - https://www.mdsabstracts.org/abstract/movement-disorders-patients-in-long-term-care-protecting-access-to-appropriate-treatment/