Spotting When Someone Is Getting Worse: Baseline, Speed and the Same Day Call

Deterioration in an older person is almost never a new symptom with a name. It is a difference from how they were, and the two questions that sort it are how big the difference is and how fast it arrived. A change over hours or a day or two is a phone call today. A drift over months is an appointment to book. That is the entire method, and the reason it works is causal rather than clinical: the things that go wrong quickly enough to change somebody in a day, such as infection, dehydration, constipation, urinary retention, pain and a new or changed medicine, are usually the things that can be fixed.

You are better placed to make that judgement than anybody else involved. Not because you know more medicine, but because you hold the only baseline in the system. A clinician sees ten minutes of a person they may have met twice. You know what they were like last Tuesday. Across England and Wales, 5.0 million people were providing unpaid care in 2021 (ONS, Census 2021, published January 2023)¹, and in the United States 63 million adults, about 24 percent of all US adults, provided care in the past year, at an average of 27 hours a week (National Alliance for Caregiving and AARP, Caregiving in the US 2025, published July 2025)². Millions of people are holding baselines that never get written down.

I learned this the expensive way. My mother went down in the kitchen at six in the morning in February 2023 and got up again. Because she got up, I filed it as an accident. It happened again in the April. What I had been given in February was information, and I threw it away. Before that, in the two days after her coronary bypass surgery in April 2022, she thought she was in the wrong building and could not follow the end of a sentence, and I had no word for it, so I said nothing.

This article is the spine that the rest of the clinical pages on this site hang off. It sits under caring for a parent at home, and everything you record here belongs in a care file.

What is a baseline, and how do you write one that is any use?

A baseline is a plain description of an ordinary day for this specific person, written down before anything goes wrong. It is not a medical record and it does not need any clinical language. Its only job is to be the thing you compare against when somebody asks you what has changed.

The version that is useful is concrete and behavioural. Vague baselines (“she is quite independent”) are useless in a phone call because no observation can contradict them. Specific ones can.

• The day’s shape. What time they get up without being woken, when they eat, when they nap, when they go to bed, and how they sleep.
• Walking and moving. How far they walk, whether they hold anything on the way, whether they can get out of that particular chair unaided, and how many times they get up in the night.
• Eating and drinking. What a normal breakfast is, whether they finish meals, and what they drink in a day.
• Conversation. Whether they can follow a story to the end or find the word they want. Not whether they are forgetful, which is too vague to be evidence.
• The things they choose to do. The crossword, the phone calls, the garden, the shopping list. These are the most sensitive markers of all, because people give them up before they give up anything a professional would ask about.
• Continence and bowels. What is normal for them, because a sudden change from it is a medical sign.
• Skin and feet. The heel that goes red, the shin that bruises, the pressure areas if they sit for long periods.

Write it once, date it, and revise it twice a year rather than continuously, so that the drift stays visible. A baseline quietly updated every time something slips becomes a running commentary, which is how families end up saying “she has been like this for ages” about a change that took six weeks.

Why is speed the first question rather than severity?

Because speed points at the cause, and severity does not. Something that has changed a person over a day or two has to have a cause fast enough to work in a day or two, and that shortlist is dominated by treatable problems. Something that has changed a person over eighteen months has a different shortlist, and almost nothing on it is urgent.

The clearest illustration is delirium, which is the fast-onset problem carers meet most often. NICE describes it as a clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and a fluctuating course, and which usually develops over 1 to 2 days (NICE guideline CG103, published July 2010, substantively updated 18 January 2023)³. It is common. The prevalence among people on medical wards in hospital is about 20 to 30 percent, 10 to 50 percent of people having surgery develop it, and in long-term care the prevalence is under 20 percent³. SIGN records up to 50 percent among people who have had a hip fracture and up to 75 percent in intensive care (SIGN 157, published March 2019, revalidated 2022, Scotland)⁴.

The sentence that should decide your behaviour is NICE’s own: delirium “is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.”³ Urgency is not an overreaction here. It is the treatment.

The mirror image is just as important. If something has taken months, ringing today will not help, and treating it as an emergency wastes the appointment you actually need, which is a longer one about what is driving the decline. Delirium or dementia sets out that distinction in full, and it is the single most useful thing on this site.

Which changes mean the same day?

Ten of them, and they are worth learning as a list rather than reasoning from first principles at four in the morning. For each one, the useful thing to say on the phone is the comparison, not the diagnosis.

• New confusion, or confusion that comes and goes through the day. Say the word confusion. Say when it started and whether it is worse at some times than others. This is the highest-yield signal a carer ever reports.
• New drowsiness, withdrawal or slowness. This is the quiet form, and the one that gets missed. NICE tells clinicians to “be particularly vigilant for changes that may indicate hypoactive delirium, which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite”³. If somebody who normally talks has gone quiet, treat it exactly as you would treat agitation.
• A fall, including one they got up from. Around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year, and the one-year mortality rate after a hip fracture is 31 percent (NICE guideline NG249, published 29 April 2025, England)⁵. See falls at home for the first minutes and the assessment to ask for.
• They have stopped eating or drinking. Not eaten less. Stopped, or nearly stopped, in someone who was eating normally last week.
• Dark, scant or strong-smelling urine, or no urine.
• A new fever, or feeling cold and clammy and not right. Older people do not always run a temperature when they are infected, so the absence of a fever is not reassurance.
• New pain, or pain that has got worse, including pain they cannot locate or describe.
• Agitation or distress that is new for them, particularly in someone who cannot tell you what hurts. Assume something hurts until that is excluded.
• A sudden change in continence. New incontinence, new urgency, or not passing urine at all. This is a medical sign, not a laundry problem, and continence and keeping dignity explains why it belongs in this column.
• New breathlessness, or breathlessness on much less effort than usual.

None of these requires you to know what is wrong. They require you to notice that something is different and to say so out loud today.

Which changes are a slow drift, and why do families miss them?

The slow ones are missed because they are absorbed. Each week is only slightly different from the last, the household adapts without discussing it, and by the time anybody says the word decline out loud the change is a year old. These are the signs to look for deliberately, because they will not present themselves.

Unintended weight loss is the most important and the most ignored, and it is measurable, which makes it the easiest thing here to turn into evidence: weigh monthly, write the number down, and take the sequence to the appointment. In BAPEN’s 2022 UK survey, 45 percent of all adults screened across UK health and care settings were at risk of disease-related malnutrition, rising to 56 percent of those screened in their own homes, with 26 percent showing unplanned weight loss⁶. Read those as proportions of adults screened in a voluntary survey rather than as population prevalence, which is what BAPEN itself says they are. On the intake side, the European guideline gives a guiding value for energy intake in older people of 30 kcal per kg body weight and day and protein of at least 1 g per kg body weight and day, individually adjusted (ESPEN practical guideline on clinical nutrition and hydration in geriatrics, published 2022, Europe)⁷.

Drinking less is the twin of it and harder to see, because nobody watches somebody else’s glass. The same guideline says older women should be offered at least 1.6 L of drinks each day and older men at least 2.0 L, unless a clinical condition requires a different approach⁷. Those are drinks rather than total fluid intake, a distinction that gets lost and understates the target when it does.

Walking less, and then less again. Fewer trips upstairs, the shorter route to the shop, the chair moved closer to the kitchen. Reduced mobility is also on NICE’s list of changes that may indicate hypoactive delirium³, so if it happened over a fortnight rather than a year it belongs in the fast column instead.

Doing less of what they chose to do, and withdrawing from people. The crossword left blank, the phone calls not made, the shopping list down from eleven items to four, visits turned down. This is usually the earliest signal of all and almost never gets reported, because it does not look medical.

More falls, or near misses that get laughed off. A pattern of stumbles is a slow-drift finding that deserves a fast response, and falls at home sets out the assessment to ask for.

Families miss these not through carelessness but because noticing them creates work, and the carer is already at capacity. If that is where you are, getting help in sets out what exists and how each thing is triggered.

Where does each sign sit, at a glance?

Here is the sorting rule in one table. Keep it somewhere you can see it rather than trying to reconstruct it under pressure.

What you notice	How fast it usually arrives	What it often means	Which column
New or fluctuating confusion	Hours to 2 days	Delirium until proven otherwise: infection, dehydration, pain, retention, medicines	Ring today
New drowsiness, withdrawal, slow responses	Hours to days	Hypoactive delirium, the form most often missed	Ring today
A fall, even one they got up from	Instant	A symptom with a list of causes behind it	Ring today
Stopped eating or drinking	Days	Acute illness, pain, swallowing problem, low mood, delirium	Ring today
Dark, scant or absent urine	Hours to days	Dehydration or retention	Ring today
New fever, or cold and clammy	Hours	Infection	Ring today
New or worsening pain	Hours to days	Anything from constipation to a fracture nobody has found	Ring today
New agitation in someone who cannot explain it	Hours to days	Pain, retention, constipation, delirium	Ring today
Sudden change in continence	Hours to days	Infection, retention, delirium, a medicine change	Ring today
New breathlessness	Hours to days	Cardiac, respiratory or infective	Ring today, or emergency if severe
Unintended weight loss	Weeks to months	Undernutrition, swallowing difficulty, an underlying condition	Book an appointment
Walking less, doing less, going out less	Months	Deconditioning, pain, fear of falling, low mood, progression	Book an appointment
Withdrawal from people and activities	Months	Low mood, hearing or sight, cognitive change	Book an appointment

The two columns are not a hierarchy. A slow drift can be more serious in the long run than an infection. They differ only in how fast the phone has to be picked up.

What do you actually say on the phone?

Lead with the comparison and the timing, and put the request at the end. Receptionists and triage clinicians are sorting by urgency, and a description that starts with the change and the speed sorts correctly. One that starts with an apology does not.

1. The comparison. “Last Tuesday she was doing the crossword and walking to the shop. Since Sunday she has not finished a meal and cannot follow a conversation.”
2. The speed and the pattern. How fast it arrived, and whether it fluctuates through the day. Say if it is worse in the late afternoon or at night.
3. The specifics you have already checked. Eating, drinking, urine, bowels, temperature, pain, any fall, any new or changed medicine, and anything that has happened recently such as a hospital stay or an anaesthetic. Having those ready is the difference between one call and three.
4. The word you think applies. If you think it is confusion, say confusion. If you think it might be delirium, say delirium. Carers rarely know they are allowed to use clinical words, and using them changes the speed of the response.
5. What you are asking for, and by when. “I am asking for her to be seen today, and I would like to know who is going to do it.” Then write down the name and the time you were given.

If somebody is assessed for delirium, the tool used in most settings is the 4AT. NICE recommendation 1.6.1, updated in 2023, says that where indicators of delirium are identified, a practitioner competent to do so should assess using the 4AT, with the CAM-ICU or the Intensive Care Delirium Screening Checklist used instead in critical care or in the recovery room after surgery³. Knowing its name is useful, because asking whether a 4AT has been done is a more specific request than asking whether somebody has looked at her. Being heard in appointments covers the longer version of this problem, which is getting your observation into a ten minute slot and into the record.

Why do carers talk themselves out of ringing?

Because the cost of ringing is visible and immediate and the cost of not ringing is invisible and delayed. You can picture the receptionist’s tone and the wasted appointment. You cannot picture the untreated infection.

Three specific traps do most of the damage.

“She was fine when the nurse came.” Fluctuation is a diagnostic feature of delirium, not evidence against it³. Describe the worst hour of the day, not the hour in which the professional happened to visit.

“She got up, so it cannot have been a bad fall.” Getting up tells you about the injury. It tells you nothing about the cause, and the cause is the reason to ring⁵.

“I do not want to waste your time.” Do not open with this. It reframes your observation as a low-value interruption before you have said what you saw. Replace it with the comparison: “She was herself last week and she is not today.” That sentence is the highest-value clinical information anybody will give that practice all morning.

There is a version that runs the other way, too. Some carers are told, repeatedly, that they are anxious. If you are being managed rather than listened to, put the observation in writing, ask for it to be added to the record, and ask what specifically would trigger a review. Keeping a care file exists largely for this.

And if you turn out to be wrong, very little happens: a clinician’s reassurance, and a note in the record that you saw a change on a particular date, which is useful the next time. If you do not ring and something is wrong, a treatable problem gets several days’ head start. The documented failure mode in this subject runs one way only. NICE records that “reporting of delirium is poor in the UK, indicating that awareness and reporting procedures need to be improved”³. Under-reporting is the problem. Over-reporting by carers is not. If you are unsure which professional a change belongs to, who does what: GP, district nurse, social worker is the cast list, and being routed to the right person costs one transferred call.

When is the risk highest?

Three windows concentrate almost all of it, and knowing them lets you watch harder for a fortnight rather than watching anxiously forever.

The days after a discharge. This is the worst-supervised period in the whole system. NICE guideline NG27 says a GP or community-based nurse should phone or visit people at risk of readmission 24 to 72 hours after their discharge⁸, and if that has not happened, make the call yourself. In England, 14.7 percent of discharges across all ages and 17.8 percent of those among people aged 75 and over ended in an emergency readmission within 30 days in 2024/25 (NHS England Digital, Compendium indicator I02040, published 27 November 2025)⁹. The United States publishes no single equivalent national all-cause rate under its readmissions programme, but the Hybrid Hospital-Wide All-Cause Readmission measure sat at 15 percent for July 2023 to June 2024 (Centers for Medicare and Medicaid Services, Care Compare, Medicare fee-for-service)¹⁰. Between 10 and 50 percent of people having surgery develop delirium³. Coming home from hospital covers that window in detail.

The days after a fall. A fall can be the first sign of an acute illness as easily as the result of one. SIGN records delirium in up to 50 percent of people who have had a hip fracture⁴. Confusion plus a fall is usually one problem, not two.

The days after any change to the medicines. A new item, a stopped item, a changed strength or a switched brand each deserve a fortnight of closer attention. You are not being asked to judge whether the change was right, only to notice if something is different afterwards. If the list has grown long over the years, NICE guideline NG5 recommends considering a structured medication review for people taking multiple medicines, people with long-term conditions and older people, taking into account the person’s and carers’ views and concerns¹¹. Managing someone else’s medication covers how to ask for one, and gives no doses, because doses belong to the prescriber and the pharmacist.

Two slower risks deserve a standing watch rather than a window: skin, covered in preventing pressure sores, and intake, covered in eating, drinking and weight loss. If dementia is in the picture, dementia care at home explains why a sudden change there is almost never the dementia progressing.

This is a call today, not a question for next week

If any of the following is true of the person you look after, ring the same day and describe the change and when it started rather than asking whether it sounds serious:

• They are more confused than they were yesterday, or the confusion comes and goes through the day.
• They have gone quiet, slow or drowsy, or have stopped finishing meals, which is the form of delirium most often missed³.
• They have had a fall, even one they got up from⁵.
• They have stopped eating or drinking, or their urine has gone dark and scant, or they have not passed urine.
• There is a new fever, new pain, worsening pain, or agitation that is new for them.
• There has been a sudden change in continence, or a new change in their breathing.

Who to ring: in the United Kingdom, their GP surgery, or NHS 111 out of hours. In Ireland, their GP or the out of hours GP service. In the United States, their own doctor’s office, or the nurse line their plan runs, or an urgent care centre. In Australia, their GP, or healthdirect on 1800 022 222. In Canada, their family doctor or the provincial health line, 811 in most provinces. Elsewhere in the European Union, their own clinician.

Use the emergency number immediately for changed breathing, chest pain, one-sided weakness, changed speech, a first seizure, an unrousable person, or bleeding that will not stop: 999 or 112 in the United Kingdom and Ireland, 911 in the United States and Canada, 000 in Australia, 112 across the European Union.

The person carrying the risk of a delayed call is not you. Everything on this page is written on the assumption that you will be tempted to wait until morning, and the whole point of holding a baseline is to make that temptation easier to refuse.