Hiding medicine in a patient's food or drink is a widespread practice yet few carers consult a pharmacist about the implications, a study has found.
The study was carried out by Dr Adrian Treloar (old age psychiatrist, Memorial hospital, London) and colleagues who say that carers in the community and in institutions seem to regard the covert administration of drugs as acceptable, for both physical and mental disorders, as a last resort. However, they say: "We were concerned about the secrecy and lack of controls, and about the absence of discussion with pharmacists regarding advisability." They suggest: "In incompetent, resistive patients, medication should be given covertly only after discussion within the nursing and medical care team, and with the family. The practice should be recorded and regularly monitored."
The researchers surveyed, by confidential questionnaire, 34 residential, nursing and inpatient units providing care for people with dementia in south-east England. In addition, they questioned 50 home carers providing care for people with dementia in the community. The results show that 71 per cent of nursing homes surveyed "sometimes resorted to concealing medicines in food or drink", although the researchers suggest that this figure may be an underestimate. Of the home carers, 96 per cent thought the practice was sometimes justifiable.
Only three homes had ever consulted a pharmacist, despite the possibility of interactions between the drugs and food or pharmacological problems arising as a result of crushing tablets. In addition, only three homes had informed a pharmacist that medicines were being covertly administered, while 14 informed a doctor and 20 the home manager. Fears that the home might lose its registration or that staff would be dismissed were suggested as reasons for secrecy surrounding the practice.
Reasons given for hiding medicine in food or drink included the prevention of mental distress or physical harm. However, 11 respondents said that the practice was justifiable only in mentally incapacitated patients. The general opinion among the home carers was that it would be right to put medicines in food if it was the only way to ensure the patient was treated.
Dr Treloar says that mentally incapacitated patients should expect good quality care even if they are unable to give valid consent or refusal. Explaining the difficulties faced by carers when deciding whether to administer drugs covertly, he says that in order to refuse medication, a patient must be able to understand and believe information about treatment and the consequences of not taking it, and be capable of assessing this information. For example, if a patient with severe learning disability who develops epilepsy refuses treatment, not understanding the need for anticonvulsant drugs, "the stark choice is either to let the patient experience further seizures and suffer harm or to medicate by giving the drugs covertly."
However, the chief executive of the Alzheimer's Society, Mr Harry Cayton, responded: "It is a denial of people with dementia's independence and dignity to give them medication without their knowledge or consent. The Alzheimer's Society cannot condone the secret giving of medication to people with dementia however good the intention."
The study is published in the Journal of the Royal Society of Medicine (2000;93:408).