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For facility staff

For facility staff

You see the change first. A shift sees today; a prescriber sees a fifteen-minute review every few months. Almost everything on this site depends on somebody noticing a difference and saying so in a way that gets acted on — and that somebody is usually you.

Why this matters more than it sounds

Two things in the evidence make the point.

  • Risk concentrates around changes. Fall risk was roughly 3.8 times higher in the 24 hours after a benzodiazepine was started, in a study of 594 long-stay nursing home residents with a mean age of 87.5. Fracture risk after an opioid is started in older adults is concentrated in the first two weeks. Pneumonia risk after an antipsychotic is started peaks in the first week. The window in which someone needs to be watching is short, and only staff are there for it.
  • The interventions that work involve you. The Cochrane evidence on reducing restraint found that organizational programs — which include trained staff champions and a change in the culture of care — probably work, while staff education on its own has an uncertain effect. In the falls evidence, multifactorial programs delivered with facility staff engagement probably produce a large reduction in falls, while those not delivered that way probably do not.

What DWARAA is not asking you to do

What DWARAA is, and is not

DWARAA does not prescribe, deprescribe, diagnose or treat. Those are decisions made by a patient and their own clinicians, with the whole record in front of them. What DWARAA supplies is the framework, the evidence behind it, and the shared vocabulary that lets a family, a nurse, a facility and a prescriber talk about the same medication list and mean the same thing.

Nothing on this site asks you to question a prescription, change anything, or withhold a medication. What it asks is that what you observe reaches the person who can act on it, in a form they can use.

The pages

What you see first

The changes that show up on a shift long before they show up in a review, and which ones are worth reporting.

How to raise a concern

The form of words that gets taken seriously, what to write down, and why timing and dates carry most of the weight.

Non-drug approaches you deliver

The eight things, what they are actually for, and why the ones that work leave no record.

Pain in residents who cannot tell you

What untreated pain looks like when the person cannot say it, and the trial that proved treating it changes behavior.

The single most useful thing you can do

Notice timing. “She has been sleepier since about the third week of March” is clinical information that a prescriber can work with. “She has not been herself” is a starting point that requires somebody else to do the detective work — and usually nobody does.

If a change in a resident followed a change in their medication, saying those two facts in the same sentence is the whole contribution. How to raise a concern.

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

  1. Berry SD, Placide SG, Mostofsky E, et al. Antipsychotic and Benzodiazepine Drug Changes Affect Acute Falls Risk Differently in the Nursing Home. The Journals of Gerontology Series A. 2016;71(2):273–278. PMID 26248560 · DOI 10.1093/gerona/glv091.
  2. Miller M, Stürmer T, Azrael D, Levin R, Solomon DH. Opioid analgesics and the risk of fractures in older adults with arthritis. Journal of the American Geriatrics Society. 2011;59(3):430–438. PMID 21391934 · DOI 10.1111/j.1532-5415.2011.03318.x.
  3. Knol W, van Marum RJ, Jansen PAF, Souverein PC, Schobben AFAM, Egberts ACG. Antipsychotic drug use and risk of pneumonia in elderly people. Journal of the American Geriatrics Society. 2008;56(4):661–666. PMID 18266664 · DOI 10.1111/j.1532-5415.2007.01625.x.
  4. Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database of Systematic Reviews. 2023;7(7):CD007546. PMID 37500094 · DOI 10.1002/14651858.CD007546.pub3.
  5. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.

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.