For facility staff
The obstacle is almost never that staff do not notice. It is that an observation gets reported in a form that is easy to reassure away, and then nothing happens, and after that happens twice nobody reports it a third time.
The shape that works
Three parts, in this order. It takes one sentence.
- What changed, specifically. “She is sleeping through breakfast” rather than “she seems tired.”
- When it changed. “Since about the third week of March.”
- What else changed around then. “Her sleeping tablet was increased on the 18th.”
That is a clinical observation. It contains a timeline and a candidate explanation, and it is difficult to reassure away because it is not an opinion — it is two dates.
Compare
| Easy to set aside | Hard to set aside |
|---|---|
| “She has not been herself lately.” | “She has been sleeping through breakfast since about March 20th. Her sleeping tablet went up on the 18th.” |
| “He seems agitated in the afternoons.” | “He gets distressed between 3 and 5 most days. It settles if we take him to the bathroom. It started about three weeks ago.” |
| “I think she is in pain.” | “She winces when we turn her and guards her left side. She has stopped using her left arm to reach. It started after the fall on the 4th.” |
| “He is more confused.” | “He was clear on Monday and confused by Wednesday, and he is worse every evening. He has not had much to drink this week.” |
You do not need to be right
This matters, because uncertainty is the most common reason an observation goes unreported. You are not diagnosing anything and you are not questioning a prescription. You are supplying a timeline that nobody else has. Whether it means anything is a clinical judgment and it belongs to someone else — but they cannot make it without the timeline.
“I do not know if this is connected, but these two things happened close together” is a complete and useful report.
Write it down
There is a structural problem worth knowing about, because it affects you directly. Interventions that work tend not to get documented. A redirection that settled someone in four minutes leaves no record; an incident leaves a form. So the written history of any building is a record of its failures, and anyone reviewing that record later will conclude that nothing works.
The corollary is practical: write down what worked, not only what went wrong. “Settles if taken to the bathroom before 3pm” is the single most valuable sentence in a care plan and it is almost never in one, because nothing happened.
What to do when nothing happens
- Put it in the record, dated. An observation in the notes survives the shift, the week and your employment. A verbal one does not.
- Repeat it with the new date. “This is the third time I have recorded this, on these three dates” is a different report from the first one.
- Attach it to a trigger. A fall, a near miss, a hospital return, or a medication change are all events that should prompt a review anyway. An observation attached to one of those travels further.
- Tell the family what you observed, if that is appropriate in your role and your building’s policy. Families are explicitly part of the assessment loop in the guidance, and they see change across time that no single shift does.
What a good response looks like
So you can tell whether you got one. A good response names what will happen and when: “I will look at the list this week,” “let us reduce it and see where she is in three weeks,” or “I do not want to change that one, and here is why.” A reason is a good answer even when the answer is no.
“That is normal for someone her age” is not a reason. Neither is “she has been on it a long time.”
Why this is worth the effort
Because the evidence says the conversation is the bottleneck, not the willingness. In one trial, patients or their families agreed with 63% of clinician deprescribing recommendations across 883 medications. In another, simply giving long-term sedative users information caused 62% of them to start a conversation with their doctor or pharmacist, and 27% had stopped six months later against 5% of those who got nothing.
People say yes. Somebody has to raise it.
What the evidence does and does not show
Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.
References
- Kim JL, Lewallen KM, Hollingsworth EK, Shah AS, Simmons SF, Vasilevskis EE. Patient-Reported Barriers and Enablers to Deprescribing Recommendations During a Clinical Trial (Shed-MEDS). The Gerontologist. 2023;63(3):523–533. PMID 35881109 · DOI 10.1093/geront/gnac100.
- Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Internal Medicine. 2014;174(6):890–898. PMID 24733354 · DOI 10.1001/jamainternmed.2014.949.
- Kales HC, Gitlin LN, Lyketsos CG; Detroit Expert Panel. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society. 2014;62(4):762–769. PMID 24635665 · DOI 10.1111/jgs.12730.
- By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.
Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.