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Just how do you make sure the medicine goes down?

Angela Bending
RGN
Clinical Nurse Specialist in Nutrition
Llandough Hospital
Cardiff
E:jspr@dircon.co.uk

The UKCC has recently introduced a position statement about the covert administration of medicines, adding fuel to the debate on hiding medication, with the RCN, Age Concern and the Alzheimer's disease Society expressing concern about the guidance. Recent research has revealed that hiding medication is a widespread practice. Tampering with medicines has implications for practice nurses as well as those in secondary care.

Medicines and the elderly
As people get older their use of medicines tends to increase. Four out of five people over the age of 75 take at least one prescribed medicine, while 36% take four or more medicines.(1) However, it is estimated that as many as 50% of older people are not taking their medicine as the prescriber intended, leading to drug wastage, inadequate treatment and sometimes even adverse reactions to the drugs prescribed. It is estimated that up to 17% of all hospital admissions relate to adverse drug reactions.

Compliance and the elderly
Poor compliance is often cited as a major concern relating to medication and the elderly. There are many reasons why patients may fail to adhere to their treatment, including a poor understanding of why they need to take their medication and a fear of potential side-effects. It is estimated that around 25% of patients cannot recall why their medicine was prescribed. Always try to explain to patients why their medication is necessary and why it is important to follow directions. It is always worth keeping in mind that a patient may have failed to comply with their drug regimen.
Many drugs are prescribed to the elderly to counteract the side-effects from another drug. This is known as the "prescribing cascade" and may in itself present problems. The British National Formulary has a section entitled "Prescribing for the elderly", which highlights the problems of polypharmacy, where elderly patients often receive multiple drugs for multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions.
More drugs can also lead to confusion as to which tablet to take at what time, especially for the elderly patient. There are various "medication reminder" products on the market, ranging from automatic pill dispensers to medical alarm clocks and vibrating watches. Information can be found on the internet or from individual suppliers.

Reassurance
Patients, when discharged from hospital back into the community, may find that the tablets they receive from their GP differ appearance from those supplied in hospital. Brands may be changed or generics may be substituted for a branded version. This can cause immense confusion and uncertainty for elderly patients. Reassurance is essential to help minimise apprehension about medication.

Size really does matter
Many elderly patients will often experience difficulties in swallowing. Some tablets are characterised by a tendency to irritate the oesophagus, resulting in gastrointestinal disturbance. Drugs known to irritate the gastrointestinal tract include doxycycline, nonsteroidal anti-inflammatory drugs (NSAIDs) and iron preparations. The gelatine coating found on capsules can often cause difficulties in swallowing. Patients should always be advised to take their medication while sitting upright and with plenty of water. Oval-shaped solid-dose forms may be easier to swallow than round ones.
If a patient finds tablets difficult to swallow, they should not be crushed or mixed with food. Most medications are available in liquid format, which can be easier and more convenient for an elderly patient.

Covert drug administration
Hiding medicines in a patient's food or drink is a frequent practice. According to recent research, 71% of nursing homes surveyed "sometimes resorted to concealing medicines in food or drink", and 96% of healthcare workers thought the practice was sometimes justifiable.(2) The psychiatrists who carried out the study voiced concern over the secrecy surrounding the practice, the lack of precautions taken and the potential for abuse.

Which patients are at risk?
The problems of drug administration are relevant to the primary care setting, particularly as it has been estimated that as many as half of all patients with chronic conditions receive their medication in a way that is not effective.(3) This could be through the covert administration of the drug, tablet crushing or capsule opening. Patients most likely to be receiving their medication inappropriately include those with dementia, psychiatric illness, the elderly and those with dysphagia - a list that encompasses many of the patients treated within primary care.

The hidden dangers of tablet crushing
Medicines are available in a variety of formulations, including controlled/modified release. These preparations prolong the time taken for a particular drug to be absorbed by the body, and it is very important that these drugs are swallowed whole. If they are damaged by crushing, then the whole dose is released over 5-10 minutes as opposed to the 12-24 hours intended. This results in an initial overdose followed by a subsequent period with no medication. Many commonly prescribed drugs are in ­modified or extended release systems and there is no way of telling just by looking at the tablet or capsule. These preparations should never be crushed. If the patient has swallowing difficulties, a liquid version should be prescribed.
Enteric-coated tablets delay the action of the drug following administration and prolong drug release. Enteric coatings offer a valuable means of reducing stomach irritation and minimise unwanted premature drug breakdown. However, crushing or chewing exposes the stomach to potentially irritant active ingredients, and this is especially hazardous with drugs known to irritate the stomach lining, such as the NSAIDs and steroids.
Many solid-dose forms are also hazardous for patients if crushed, including Slow K (potassium chloride; Alliance), sulphasalazine and calcium supplements.
The crushing, opening or breaking of medicaments that have carcinogenic properties (antineoplastics) may not only alter the delivery mechanism, but can also lead to unwanted airborne release of particles, thus exposing the carer to the dangers of cytotoxic activity. An example is tamoxifen, which is routinely prescribed in breast cancer management; this drug can be prescribed as a liquid medication, Soltamox (Rosemont).

Legal implications
Each drug has a product licence, which states the conditions for which the medication may be suitably administered, the range and frequency of dose, route and manner of administration. A nurse or healthcare professional that administers a medicine in a way outside the product licence undertakes a degree of liability for any adverse effects caused by this administration. Crushing of tablets or opening of capsules falls outside the product licence of most drugs, as does mixing medication with food and drink before administration.
A nurse or carer who is faced with giving medication outside its product licence should take steps to lessen any personal liability. This can be achieved by getting the medication changed to a suitable, possibly liquid alternative, or by obtaining confirmation in writing from the prescriber or the pharmacist that the administration is appropriate. Taking a decision to crush, open or hide the medicine is not an option.

What if a patient refuses medication?
Does a patient have the right to refuse medication? For a person to give consent they need to be mentally capable of understanding an explanation, able to make a choice, and able to communicate in some way, without being under undue pressure. Every mentally competent person has a right to give or withhold consent to treatment unless there are exceptional circumstances. Legally, exceptional circumstances include treatment given where the carer is "acting in the best interests" of the patient unable to give consent, and who is "following a reasonable standard of care". If a resident is not capable of giving their own consent, there is no power in law for someone to give consent for them. However, the courts have accepted that treatment can be carried out by a doctor if it is in the best interests of the patient.

Liquid alternatives
When patients experience difficulty in swallowing, the use of elixirs, mixtures or solutions may offer a convenient alternative. Some patients may even derive psychological benefit from taking a brightly coloured liquid rather than a white tasteless pill. Many pharmacies in the UK employ the services of specialised manufacturers of liquid preparations, and such companies offer a huge range of licensed liquid alternatives to solid-dose medicaments. Most solid medications are available as liquid preparations, even when not listed in MIMS (Monthly Index of Medical Specialities) or the British National Formulary.

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References

  1. Department of Health.National Service Framework: Medicines and older people. London:HMSO; 2001.
  2. Treloar A, Beats B, Philpot M. A pill in the sandwich: covert ­medication in food and drink.J R Soc Med 2000;93:408-11.
  3. Department of Health.Pharmacy in the future - implementing the NHS plan. London: HMSO; 2000.

Resources
Age Concern
W:www.ace.org.uk
National Service Framework for Older People
W:www.doh.gov.uk/nsf/olderpeople.htm
UKCC
W:www.ukcc.org

Further reading
UKCC. Guidelines for the ­administration of medicines.
London: UKCC; 2000.

Forthcoming events
Rosemont Pharmaceuticals are organising a series of study days for nurses about medication and the elderly.
For more information contact Julia Daniels
T:0113 244 1400