Dementia
28
Monitoring
STEP 18: Perform regular re-assessment of mental status,
functional capability, and treatment plan
➤ If treatment target is functional improvement with cholinesterase
inhibitors or memantine, standard practice for nursing home
residents should include a yearly assessment of mental status to
track progress. Additionally if functional decline progresses or there
is a concern for side effects, treatment indication should be revisited.
➤ If treatment target is a behavioral symptom in dementia, it should be
carefully documented and promptly followed-up after initiation of a
pharmacological agent. Recommended steps are listed below:
• Thoroughly document behavioral symptom including context and scope/severity.
• Clearly document target symptom if initiating pharmacological management.
• Start with lowest dose and titrate slowly. Do not expect an immediate response.
Sedation may explain much of the immediate effect.
➤ Within the first year in which a resident is admitted on a psychotropic
medication or after the prescribing practitioner has initiated a
psychotropic medication, the facility must attempt a gradual dose
reduction (GDR) in two separate quarters (with at least one month
between the attempts), unless clinically contraindicated. After
the first year, a GDR must be attempted annually, unless clinically
contraindicated.
➤ GDR may be indicated when the resident's clinical condition has
improved or stabilized, the underlying causes of the original target
symptoms have resolved, and/or non-pharmacological approaches
have been effective in reducing the symptoms.
STEP 19: Monitor for adverse effects of antipsychotics
➤ Review Appendix A and B; pay particular attention to movement
disorders, extrapyramidal symptoms, sedation, orthostatic
hypotension, weight gain, diabetes, triglyceridemia.
Information regarding PRN antipsychotic and PRN psychotropic medications can
be found in Appendix G with link to Centers for Medicare & Medicaid Services (CMS)
Guidance and F-Tag 758 Free from Unnecessary Psychotropic Meds/PRN Use.
