Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Care-home medicine
Medicine of older adults · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Care-home resident with acute deterioration
New hypoxia, hypotension, reduced consciousness, focal neurology, severe pain, head injury, sepsis features, retention, uncontrolled bleeding or inability to provide essential care requires immediate assessment and proportionate escalation.
Action: Use ABCDE and glucose, obtain the resident's baseline, advance decisions and exact medicines from care records, provide time-critical treatment and contact emergency services or urgent community pathways without allowing transfer documentation to delay resuscitation.
Overview
Deliver proactive, person-centred medical care in a care home, recognise acute illness against an observed baseline, prevent medicine and transition errors, and coordinate residents, families, care staff, primary care and specialist services around function and goals.
Build a concise baseline summary for every resident: diagnoses, frailty, cognition and communication, capacity supports, mobility and transfer method, ADLs, continence, swallowing and texture, nutrition, pressure risk, medicines, allergies, sensory aids, advance decisions and important relationships. State what a good day looks like. This makes subtle changes such as sleeping through breakfast or needing two-person transfer clinically meaningful.
When staff report not themselves, ask exactly what changed, over what hours, and what was measured. Use ABCDE, capillary glucose and appropriate observations. Examine the likely systems, skin, mouth, hydration, abdomen, bladder, bowel, neurology and injury. Obtain 4AT for possible delirium and compare with staff who know the resident. Do not substitute remote urine testing for a clinical assessment.
Practice
Two practice questions
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Medicine of older adultsOriginal SBA
Meaning of a DNACPR decision
A care-home resident with a DNACPR decision develops a painful suspected hip fracture after a fall. Which statement is correct?
Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Create a clear escalation route. Staff should know when to call emergency services, urgent community response, GP or pharmacy and what information to provide. A transfer pack includes baseline, current change, observations, medicine administration record, last time-critical doses, allergies, advance decision and legal representative details. Treatment should begin when indicated rather than waiting for paperwork to become perfect.
Medicines management follows NICE SC1. Reconcile after admission, hospital return and every material change. The MAR must match the authorised prescription and actual supply, including formulation and timing. Record omissions and reasons and escalate time-critical delays. Staff need competency for administration, covert medicine processes, PRN assessment, controlled drugs, patches, insulin, anticoagulants and enteral tubes.
A PRN prescription must state indication, dose, interval, maximum and what response is expected. Repeated use triggers clinical review rather than indefinite administration. Patches require site, date and removal records. Crushing or opening medicines requires prescriber and pharmacy authorisation and a lawful decision process; adding crushed medicine covertly is not an informal convenience.
Structured medication review integrates goals and risk. Prioritise psychoactive and anticholinergic burden, falls, hypotension, hypoglycaemia, constipation, retention, renal and swallowing issues. Check whether monitored packaging and care rounds support the intended timing. Include the resident with communication support; relatives contribute history but do not automatically consent without legal authority.
Prevent common syndromes proactively. Use hydration and bowel plans, nutrition and weight monitoring, mouth and dental care, pressure redistribution, falls exercise and safe toileting. Ensure glasses, hearing aids and batteries remain available. Review catheters, oxygen, wounds and diabetes devices. These routine systems determine whether frailty remains stable between clinician visits.
Treat delirium as an acute syndrome. Assess infection, hypoxia, pain, medicine effects, withdrawal, retention, constipation, dehydration and environment. Provide familiar staff or family, orientation, sensory aids, sleep, food, movement and calm communication. Reserve antipsychotic treatment for exceptional severe distress or immediate risk after de-escalation and contraindication review.
Advance care planning begins with values, feared outcomes, preferred place and acceptable treatment burdens. Record and review decision-specific advance decisions, emergency care plans, lasting power of attorney and resuscitation decisions. DNACPR concerns CPR only. A resident with a valid ceiling for intensive care can still receive urgent examination, fracture treatment, antibiotics, fluids, oxygen and comfort care consistent with goals.
Support current capacity. Explain the specific decision in an accessible way, at the best time and with aids or interpreter. If capacity is lacking, use the Mental Capacity Act best-interests process, consult relevant people and consider prior wishes and the least restrictive option. Covert medication requires a formal best-interests decision and pharmacy plan, not a blanket authorisation.
Manage infection without eliminating life. Maintain vaccination, hand and respiratory hygiene, ventilation, cleaning, device care and appropriate PPE. Recognise respiratory or diarrhoeal clusters early and contact health-protection services under local arrangements. Use proportionate, time-limited isolation and preserve communication, mobility and nutrition wherever safely possible.
Review outcomes in regular multidisciplinary meetings: acute events, falls, wounds, weight, medicines, hospital use, behaviour, function and resident goals. Assign actions across primary care, pharmacy, care staff, community nursing, therapies, dentistry, specialists and families. After any hospital visit, verify that new instructions are intentional, supplied and feasible in the home.
Key points
Know each resident's baseline cognition, communication, mobility, continence, intake, weight, medicines, escalation plan and preferred contacts before illness occurs.
First-line deterioration assessment uses ABCDE, glucose, observations, 4AT when appropriate and a precise description of what changed from baseline.
Do not diagnose UTI from confusion plus a positive urine result alone; assess local urinary and systemic infection features and alternative delirium causes.
NICE SC1 requires accurate medicines records, clear responsibilities, trained administration, timely supply, reconciliation and incident learning in care homes.
Time-critical medicines need resident-specific administration windows and escalation for delayed or omitted doses.
Review anticholinergic and sedative burden, falls, swallowing, renal function and treatment goals through regular structured medication review.
Advance care planning records values and preferred approaches, but no document replaces assessment of a new reversible illness or current capacity.
A DNACPR decision applies to cardiopulmonary resuscitation and does not mean no hospital transfer, antibiotics, fluids or active symptom care.
Infection prevention combines vaccination, hand and respiratory hygiene, ventilation, appropriate PPE, device care, cleaning and prompt outbreak reporting.
Transitions need one reconciled medicine list, baseline and mobility description, capacity and legal information, pending results, equipment and named follow-up.
Aetiology
01
Multimorbidity and frailty
Several diseases and limited reserve create non-specific deterioration, competing treatments and rapid functional consequences from modest illness.
02
Cognitive and communication impairment
Dementia, delirium, aphasia, hearing and visual loss make symptoms, consent and treatment response harder to recognise.
03
Medicine-system complexity
Multiple prescribers, monitored administration, supply cycles and hospital transitions create omissions, duplication, delay and documentation mismatch.
04
Shared-environment exposure
Close living, staff movement, devices and communal activity increase transmission while isolation measures can worsen mobility and cognition.
Pathophysiology
1
Baseline-dependent recognition
Disease becomes visible as a change in eating, behaviour, continence or transfers because classic symptom reporting is limited.
2
Reserve threshold crossing
Infection, pain, dehydration or medicine change pushes cognition and function below the level required for daily independence.
3
Care-process amplification
Delayed assistance, missed administration, immobility and unfamiliar transfer can compound the original disease through delirium and deconditioning.
4
Transmission network
Residents, staff, visitors, shared air and equipment connect vulnerable hosts, allowing respiratory and gastrointestinal outbreaks to spread quickly.
5
Institutional treatment burden
Frequent observations, transport, restrictions and complex regimens can displace sleep, meals, activity and relationships that sustain wellbeing.
Clinical features and red flags
Baseline departure
A new transfer, meal, communication or continence failure is observed by staff who know the resident.
Delirium pattern
Attention and arousal fluctuate acutely, often with sleep reversal, withdrawal or altered behaviour.
Act on hypoxia, pressure, respiratory, temperature, consciousness and glucose change and consider blunted responses in frailty.
034AT and delirium cause assessment
Why
Detect acute brain dysfunction and precipitants.
Interpretation and limitations
Use collateral and assess infection, pain, retention, loading, hydration, medicines, sleep and environment; no single test identifies cause.
04Medicine administration reconciliation
Why
Find omissions, duplication and formulation errors.
Interpretation and limitations
Compare MAR, prescription, supply, discharge list and last doses, prioritising time-critical and high-risk medicines.
05Targeted laboratory and imaging tests
Why
Investigate a clinically supported cause.
Interpretation and limitations
Use bloods, culture, ECG, radiograph, bladder scan or injury imaging according to examination rather than blanket testing.
06Nutrition, skin and functional assessment
Why
Identify preventable secondary physical and functional decline.
Interpretation and limitations
Track weight, intake, swallow, pressure areas, transfers, walking and toileting against baseline and current care delivery.
07Capacity, advance-plan and support review
Why
Make lawful proportionate treatment decisions.
Interpretation and limitations
Confirm current capacity, advance decisions, legal representatives, goals, family information and whether the home can deliver the plan.
Differential diagnosis
01
Acute physical illness
Infection, hypoxia, vascular disease, injury, retention, loading and metabolic disturbance commonly present as behavioural or functional change.
02
Delirium or dementia progression
Abrupt fluctuating inattention differs from gradual decline and should trigger cause assessment with collateral from familiar care staff.
03
Medicine-related deterioration
Sedation, anticholinergic effects, hypoglycaemia, hypotension, accumulation and missed time-critical treatment produce overlapping cognitive and functional presentations.
04
Environmental or psychological distress
Pain, noise, isolation, bereavement, unfamiliar carers and unmet communication needs can alter behaviour without a new infection.
05
Safeguarding or support failure
Neglect, abuse, staffing gaps, unavailable equipment and poor food or fluid access may be causal rather than incidental.
Management
01First-line deterioration routeDescribe, stabilise and diagnoseFirst stepFirst lineCare staff identify a new cognitive, physiological or functional change.+
1State exact onset and baseline departure and use ABCDE, glucose, observations, delirium and focused examination.
2Treat emergencies, reconcile time-critical medicines and select tests and referral from the clinical syndrome.
3EscalationRecord treatment, monitoring, escalation and goals in instructions care staff can deliver and observe.
02Medicine governance routeMake administration accurate and lawfulA prescription, MAR, supply, formulation or resident decision creates uncertainty.+
1Reconcile authorised treatment with actual stock, administration, indication, timing, allergy and transition documents.
2Obtain prescriber and pharmacy clarification for crushing, route, PRN, covert or high-risk administration and document capacity processes.
3Monitor clinical response and incidents, update every record and use review to prevent recurrence.
03Avoidable transfer routeTreat in place when safe, transfer when neededAcute illness may be manageable through community services but deterioration risk exists.+
1Assess physiology, diagnosis, treatment need, available nursing and diagnostics, goals and likely transfer benefit or burden.
2EscalationUse urgent community, virtual ward or specialist support only when monitoring and escalation can be delivered reliably.
3Transfer promptly for unstable physiology, time-critical intervention or unmet care needs with baseline and treatment information.
04Proactive continuity routePrevent the next crisisThe resident stabilises after illness, admission or a significant care review.+
1Review medicines, hydration, bowel, falls, pressure, nutrition, vaccination, sensory aids and advance-care preferences.
2Assign measurable actions to GP, pharmacy, care staff, nursing, therapy, specialist and family participants.
3Confirm supplies and follow-up and revisit baseline and goals after further functional or health change.
Complications
01
Avoidable hospital transfer
Delayed proactive care or absent treatment plans can turn manageable deterioration into crisis and disruptive admission.
02
Delirium and deconditioning
Illness, transfer, isolation and bed rest produce prolonged cognitive, mobility and continence decline after the acute trigger resolves.
03
Medicine harm
Administration errors, delayed doses, unsafe crushing and outdated lists cause toxicity, withdrawal and disease destabilisation during routine care.
04
Outbreak and social restriction
Transmitted infection causes morbidity and staffing pressure, while prolonged blanket isolation harms mood, eating and function.
05
Carer and placement breakdown
Unclear goals, repeated crises and conflict with families or services can make an otherwise suitable placement unsustainable.
Monitoring and follow-up
Track the resident's agreed baseline functions and record exact departures rather than not themselves alone.
Audit time-critical, omitted, delayed and PRN medicines and review repeated events clinically and organisationally.
Review falls, pressure injury, weight, intake, bowel, bladder, hydration and hospital transfers in multidisciplinary meetings.
Repeat capacity assessment for new material decisions and review advance plans after major illness or preference change.
Monitor device need, including catheter, oxygen, tube, patch and glucose technology, with trained care and escalation.
During outbreaks, maintain a line list, symptoms, testing, staff impact, public-health advice and proportionate restrictions.
After every transition, confirm the new list, supply, follow-up and functional plan are implemented rather than filed.
Special situations
Care staff hold longitudinal data
A carer's observation of a changed transfer or meal can be more diagnostic than one unfamiliar examination.
MAR is evidence, not the whole history
A signed record shows administration was documented but not whether swallowing, response or supply was clinically effective.
DNACPR is narrow
It governs cardiopulmonary resuscitation and cannot be expanded silently into a no-treatment instruction.
PRN use is a clinical signal
Repeated rescue dosing may reveal pain, delirium, unmet need or an ineffective regular plan.
Avoided admission still needs infrastructure
Treatment in place is safe only when examination, medicines, monitoring and escalation can actually be delivered.
Common pitfalls
01
Accepting not themselves without a baseline and acute clinical assessment.
02
Diagnosing UTI from a positive urine test and confusion alone.
03
Using standard medication-round times for resident-specific time-critical therapy.
04
Crushing or covertly administering medicine without pharmacy and lawful decision processes.
05
Interpreting DNACPR as no hospital transfer or active treatment.
06
Avoiding admission without reliable in-home monitoring and escalation.
07
Using blanket isolation longer than infection-control need without mitigating harm.
08
Filing discharge instructions without reconciling supply and MAR implementation.