Ask what they take to get to sleep, in their own words

The medication list in an older person's notes is a record of what was prescribed, not of what is taken, and the gap between the two is widest at bedtime. Antihistamines bought over the counter, a relative's benzodiazepine, an ayurvedic or herbal sleep preparation, alcohol, cannabis in whatever local form — none of these appear on a repeat prescription, and all of them contribute to falls, confusion and daytime somnolence.

The question that works is specific and non-judgemental: what do you take, or do, to get to sleep on a bad night? Not 'are you taking anything else' — that invites a no. Ask about the bad nights, not the average one, and ask separately about things bought, things borrowed and things brewed. Where a spouse or adult child is present, ask them too, after asking the patient.

Then do the arithmetic that follows. Any anticholinergic sleep aid belongs in the anticholinergic burden score. A borrowed benzodiazepine explains a fall better than most other candidates. And a patient using something nightly for sleep has an insomnia problem you have not yet assessed, which is usually more treatable than the drug is dangerous.

• Ask what they take on a bad night, not whether they take anything.
• Ask separately about bought, borrowed and herbal preparations, and about alcohol.
• Add over-the-counter antihistamines to the anticholinergic burden calculation.
• Treat nightly use of any sleep aid as an unassessed insomnia problem.
• Corroborate with the person who lives with them, after asking the patient first.

Why it matters

The drugs most often behind a fall or new confusion in an older person are the ones nobody prescribed.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.