For facility staff
Most of what matters here is a difference from yesterday, and differences are only visible to someone who was there yesterday.
The changes worth reporting
- More sleepy, slower, less talkative than last week. The most important single observation on this page, because of where it goes if nobody says it. Sedation gets written down as decline; decline gets attributed to the dementia; the care plan is adjusted for someone further along than they are. Nothing was prescribed at the last step, and the person has lost ground they did not have to lose.
- Confusion that came on quickly, or that comes and goes through the day. That pattern is different from dementia progressing, and it usually has a cause: an infection, dehydration, constipation, pain, urinary retention, or a medication. It is worth reporting in exactly those words — “this came on over two days” or “she is clear in the morning and confused by evening.”
- Unsteadiness, or dizziness on standing. Particularly if it is new. A drop in blood pressure on standing is measurable in three minutes and gets skipped constantly.
- A new or changed behavior. Which is a question before it is a symptom.
- Not eating, not drinking, or a change in the bathroom pattern.
- Anything that started after a medication change — in either direction. A medication being stopped is as much a change as one being started.
Timing is the information
A prescriber reviewing a list can see what is on it. What they cannot see is when the person changed. That is the piece only you hold, and it is the piece that turns a list into a decision.
Two dates make an observation actionable: when the medication changed, and when the person changed. If those are within a few weeks of each other, that is worth saying out loud even if you are not sure it means anything. Deciding whether it means anything is somebody else’s job; noticing it is yours.
The windows where risk concentrates
Three separate bodies of research point at the same practical fact: the dangerous period is around a change, not during steady treatment.
| Change | When risk is highest | What to watch for |
|---|---|---|
| A benzodiazepine or sleeping tablet is started or increased | Fall risk roughly 3.8 times higher in the first 24 hours in one nursing home study | Unsteadiness, confusion, daytime drowsiness |
| An opioid is started | Fracture risk concentrated in the first two weeks | Unsteadiness, drowsiness, confusion, constipation |
| An antipsychotic is started | Pneumonia risk highest in the first week; fracture risk measured in the first 30 days | Chestiness, swallowing difficulty, stiffness, unsteadiness, sleepiness |
| Any medication is stopped | Withdrawal effects vary by class and can appear over days to weeks | Return of the original symptom, sleeplessness, agitation, sweating, tremor |
None of this means those medications are wrong. It means the days after a change are when someone needs to be looking, and you are the person who is there.
What “not herself” usually resolves into
It is worth breaking that phrase down before reporting it, because the specific version is far more useful.
- Sleepier · slower to respond · sleeping through activities she used to join
- More confused · confused at a particular time of day · does not recognize a room she knows
- Unsteady · holding furniture · reluctant to stand
- Not eating · not drinking · pocketing food · trouble swallowing
- More distressed · distressed at a particular time · distressed during a particular task
- Quieter and withdrawn — which is easy to miss, because it makes a shift easier
That last one deserves its own line. A resident who has become quiet and undemanding is not a problem to manage, so nobody raises it. It is also exactly what oversedation looks like.
You are also the baseline
A change can only be detected against a starting point, and in practice the starting point often lives in the memory of the people who work with someone rather than in the record. That is fragile — it walks out with turnover and it does not transfer to agency cover.
Which is why writing down what someone is normally like has more value than it appears to. It is the thing that lets the next person notice. Assessment.
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
- 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.
- 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.
- 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.
- Torstensson M, Leth-Møller K, Andersson C, Torp-Pedersen C, Gislason GH, Holm EA. Danish register-based study on the association between specific antipsychotic drugs and fractures in elderly individuals. Age and Ageing. 2017;46(2):258–264. PMID 27932365 · DOI 10.1093/ageing/afw209.
- Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011;40(1):23–29. PMID 21068014 · DOI 10.1093/ageing/afq140.
- Han L, McCusker J, Cole M, Abrahamowicz M, Primeau F, Elie M. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Archives of Internal Medicine. 2001;161(8):1099–1105. PMID 11322844 · DOI 10.1001/archinte.161.8.1099.
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.