Concealment of drugs in food and beverages in nursing homes: cross sectional study

Covert administration of drugs

If any drugs had been concealed in the food or beverages during the previous seven days without the patient's knowledge or consent, we recorded it, along with the reason for hiding the drugs. We recorded drugs given on a regular basis as well as those given on special occasions (prn) and grouped them according to the Anatomical Therapeutic Chemical Classification (ATC-code). We did not record drugs applied directly on the skin, ear drops, or eye drops. As the use of prn drugs was not specified by date and frequency, we could not include it in the analysis. We lacked data about drugs for one patient; 32 patients did not receive any drugs, either on a regular basis or prn; and 20 patients had only prn drugs. We thus analysed data from 1873 patients.

If the interviewee stated that the patient had received covert drugs, we recorded whose decision it was to give them this way, the reason for the concealment, and whether the drugs were covert in food or beverages every time the patient received drugs (as a routine) or only in exceptional cases. We also asked whether covert administration was documented in the patient's records.

Patients' characteristics

We used a standardised interview, including rating scales, to ask the professional carer about the patient's function. We then calculated degree of cognitive impairment, function in activities of daily living, and behavioural disturbances.

We scored the degree of cognitive impairment, consistent with dementia, by means of the clinical dementia rating scale.16 17 This scale ranges from 0 (no impairment) to 3 (severe impairment). Previous studies have shown that the scale is reliable and can be treated as a dummy variable with a cut-off point between 1 and 2 for no or mild dementia and moderate to severe dementia.18 Patients with a score of 0 or 1 are probably capable of giving consent to treatment, whereas patients with a score of 2 or 3 have little capacity or are incapable.

We scored performance in activities of daily living according to the Lawton self maintenance scale,19 which ranges from 6 to 30. We divided the scores into four logical groups: group 1 = 6-13, needing little or no help; group 2 = 14-17, needing some help; group 3 = 18-21, needing a lot of help; and group 4 = 21-30, needing help with everything. We used a cut-off point between 2 and 3 to dichotomise performance into “high function” and “low function.”

We scored behavioural disturbance according to the brief agitation rating scale,20 consisting of 10 items. Each item can be scored from 1 to 7; a high score indicates disturbed behaviour. A factor analysis of the items has shown that three items cluster into a group termed “physically aggressive behaviour,” and three items cluster into non-aggressive agitation; the remaining items do not show any clear grouping pattern.18 We recorded a patient as aggressive if at least one of the items for aggressive behaviour scored at least 3 (the behaviour was present at least once during seven days). We used the same principle for non-aggressive agitation.

Ward characteristics

We defined wards with up to 12 beds as small and those with more than 12 beds as large. We calculated the staffing ratio by dividing the number of carers on an ordinary morning shift by the number of beds. The median staffing ratio was 0.32, and we used this as the cut-off point between high and low staffing.18 The mean (SD) staff ratio in regular units was 0.30 (0.07), compared with 0.36 (0.09) in special care units. Of the special care units, 71% (62; 3 missing) had a staff:patient ratio higher than average, compared with 37% (58; 2 missing) of the regular units.

Statistics

For the descriptive statistics we used SPSS version 12.02. Because we got data at two levels (patient level and ward level), we built a multilevel model for the regression analysis by using MLwiN version 2.0.21

Types of drugs

Our study shows that life sustaining treatment, such as drugs for cardiovascular diseases, were significantly more often given to patients who got drugs openly, compared with those who got drugs covertly. Drugs used for other physical disorders did not differ significantly between the two groups, except for anti-infectives (table 1), which were given more often to patients who got drugs covertly. Antiepileptics, antipsychotics, and anxiolytics are drugs that may be used as sedatives. These drugs were significantly more often given to patients who got drugs covertly, probably to control and sedate demented patients with disturbed behaviour. This assumption is strengthened by the fact that the degree of dementia and aggression are strongly associated with covert administration. We think that the term “chemical restraint” is a good description when psychotropic drugs are used for sedation, because these drugs do in fact restrain the patient. Sedation may in turn lead to the worsening of already poor function in activities of daily living (table 3), leading to a poor quality of life. By involving the family in cases in which psychotropic drugs are given to patients with dementia, the use of such drugs will probably be reduced. Treloar et al thought the same, however, but found that family members were no more concerned about the use of psychotropic drugs than were staff.11 Thus, to raise the general awareness of covert administration as an ethical and legal problem and the use of psychotropic drugs with their potential side effects, involving the families of the patients will not be sufficient.

Type of ward

Table 3 shows that teaching nursing homes and high a staffing ratio are associated with the lower use of the practice of mixing drugs in the patients' food or beverages. The reason is probably that teaching nursing homes offer educational programmes to the staff in order to improve the quality of care. Wards with a higher staff ratio may also have the opportunity (time) to run educational programmes for the staff. We had expected that fewer patients in special care units than in regular units would have been subjected to covert administration, because the staff in a special care unit are usually more highly trained and aware of the patients' needs, but the reverse was true. The most likely explanation is that the proportion of patients with a severe degree of dementia and behavioural problems is extremely high in special care units. Hiding the sedative drugs in food and beverages may in many cases be the only way of administering the drugs, because of the non-cooperation of patients who may lack the capacity to understand and give consent to drug treatment.

Who takes the decision?

We are concerned that the physician responsible for medical treatment in nursing homes is not involved in all cases in which it is decided to give drugs covertly. We believe that such involvement would reduce the frequency of the practice, or at least that the practice would be better documented. A Swedish study showed that the quality assurance of drug administration was positively associated with the quality of the communication between the physician and the nurses, and was higher in nursing homes where discussions about drug treatment took place in the multidisciplinary team.22 Nygaard et al have reported that in nursing homes with a full time physician the use of antipsychotic drugs is lower than in nursing homes where a physician works part time.23 Even though these two studies did not include covert administration, the importance of an interested physician, cooperating with other health personnel in the nursing home to reduce the use of covert administration, might be substantial.

Conclusion

The practice of mixing drugs in patients' food and beverages is common in Norwegian nursing homes but is poorly documented in the patients' records. The procedure for the decision to hide drugs seems to be arbitrary.