A — the sixth step
Adjusting care plans on ongoing evaluation means reviewing a resident’s plan at regular team meetings and after every trigger: a fall, a medication started or stopped, a new behavior, a return from the hospital, or a concern raised by family.
The last letter decides whether the other five were real. A plan written on admission describes a person who no longer exists a year later. A care plan that never changes is not being used; it is being stored.
What should a nursing home care plan include?
- An individualized plan to manage behavior without restraint.
- Built in collaboration with the prescriber, the family and the caregivers who deliver it.
- Reviewed at regular team meetings, and actually adjusted.
- Known to every staff member who works with that person.
Why do nursing home care plans fail?
A plan the day shift follows and the night shift has never read is not a plan; it is a document. In a building with agency cover, high turnover or a float pool, transmission is the whole problem. The practical test is not whether the plan exists. It is whether somebody who started three weeks ago can say what settles this person.
What should trigger a care plan review?
- A fall, or a near miss.
- A medication change in either direction — starting one as much as stopping one. Risk in this population is concentrated at initiation and at abrupt stopping, not in the steady state.
- A new or worsening behavior, which is a question before it is a symptom.
- A hospital admission and return, which is when medication lists change most and when nobody has reconciled them yet.
- A family raising something. Families see change across time that no single shift does.
Why should starting a new medication trigger a care plan review?
Three separate literatures converge on the same point. Hip fracture risk with benzodiazepines and Z-drugs is highest in newly prescribed patients. Fracture risk after starting an opioid in older adults with arthritis is concentrated in the first two weeks. Pneumonia risk after starting an antipsychotic is highest in the first week. Antipsychotic fracture risk in a nationwide cohort of adults over 65 was measured specifically in the first 30 days.
A care plan that reviews changes only when something goes wrong is reviewing them after the window in which they were most dangerous.
The tapering attempt is part of the plan
For antipsychotics specifically, the American Psychiatric Association guideline builds review into the prescription itself: if there is no clinically significant response after a four-week trial at an adequate dose, taper and withdraw; if there is a response, attempt a taper within four months of starting unless previous attempts caused recurrence; and assess at least monthly during the taper and for at least four months after discontinuation. That is a plan with review built in rather than bolted on.
The Cochrane review of antipsychotic withdrawal supports that shape, with one important qualification: withdrawal usually succeeds without symptom rebound, but people who had responded well to the drug for psychosis, aggression or agitation, and those with more severe baseline symptoms, were more likely to relapse. Which is precisely why the answer is a monitored attempt rather than a policy.
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.
How can families take part in a nursing home care plan?
Families should be encouraged to participate, informed about alternatives to restraint, and kept in open communication about strategy. A relative knows what settled this person in 1998, which no assessment tool can recover. The family track.
Frequently asked questions
How often should a care plan be reviewed?
On a regular schedule and on every trigger — a fall, a medication change in either direction, a new behavior, a hospital return, or a family raising something. The scheduled review catches drift; the triggered review catches events. Neither substitutes for the other. Measuring what changed.
What if a reduction has to be reversed?
Then it is reversed, and that is information rather than failure. A reduction that turns out to have been wrong tells you the drug was doing something, which is worth knowing and was not knowable in advance. This only works if restarting was a planned option from the beginning. Tapering principles.
Who should be involved in a nursing home care plan?
The prescriber, the family and the caregivers who actually deliver the care should build it together. Families see changes over time that no single shift sees, and they often know what settled this person years ago. Once written, the plan has to be known to every staff member who works with the resident, including night shift, agency and float staff, or it is only a document.
Can you give an example of a care plan for a nursing home?
Take a resident whose agitation is managed without restraint. The plan names what settles this person, was built with the prescriber, the family and the aides, and is reviewed at regular team meetings. It is reopened after a fall or near miss, any medication started or stopped, a new behavior, a return from the hospital, or a concern from family. The test: can someone who started three weeks ago say what settles this person?
How do you draw up a nursing home care plan?
Start with an individualized plan to manage behavior without restraint. Build it with the prescriber, the family and the caregivers who will carry it out. Make sure every staff member on every shift knows it. Set it for review at regular team meetings and after every trigger. For an antipsychotic, write the review into the prescription itself: a four-week check, and a taper attempt within four months for those who respond.
DWARAA is six steps. Back to the framework overview.
References
- Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. 2016;173(5):543–546. PMID 27133416 · DOI 10.1176/appi.ajp.2015.173501.
- Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.
- Donnelly K, Bracchi R, Hewitt J, Routledge PA, Carter B. Benzodiazepines, Z-drugs and the risk of hip fracture: A systematic review and meta-analysis. PLoS One. 2017;12(4):e0174730. PMID 28448593 · DOI 10.1371/journal.pone.0174730.
- 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.
- Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
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.