Concealment of drugs in food and beverages in nursing homes: cross sec
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《英国医生杂志》
1 Norwegian Centre for Dementia Research, Vestfold Mental Health Care Trust, T?nsberg, Postbox 64, N-3107 SEM, Norway, 2 Norwegian Centre for Dementia Research, Department of Geriatric Medicine, Ullevaal University Hospital, Oslo, Norway
Correspondence to: ? Kirkevold oyvind.kirkevold@nordemens.no
Abstract
Several studies have described the use of drugs, including psychotropic agents, in the care of elderly people.1-5 In situations in which psychotropic drugs are prescribed to sedate and control patients, the practice is often called "chemical restraint."6-8 Although the use of psychotropic drugs has been said to erode an elderly person's autonomy and decision making skills by means of sedation,8 covert administration of drugs has been little studied. The concealment of medicine in food or beverages is described in non-scientific articles,9 10 and must be a well known practice among carers in nursing homes, but we found only a few scientific papers that report the practice of covert administration. Treloar et al reported that 71% of residential, nursing, and inpatient units in southeast England at least sometimes administered drugs covertly in food and beverages.11 However, the paper did not report how many residents received drugs in this way. This paper caused some debate in Britain about the ethical aspects of covert administration.12-14 An earlier Norwegian questionnaire study reported that 46% of the wards offering residential care for elderly patients sometimes hid drugs in the patients' food or beverages.15
In Norway the municipalities are responsible for nursing home care. No legislation allows that drugs can be concealed in the patients' food. According to the Act on Mental Health Care and Patients' Rights, drugs can, in some very special circumstances, be given to patients without their consent, but not concealed. The aim of this study was to describe the characteristics of patients and wards relating to the practice of mixing drugs in patients' food or beverages, to explore the reasons for such a practice, and to find out who decided that such an action should be taken. Furthermore, we wanted to examine how this practice was documented in the patients' records.
Methods
The proportion of patients in regular units with a clinical dementia rating scale score of 2 or 3 was 59% (803; 9 missing), compared with 91% (510; 2 missing) in special care units. Drugs were given covertly to 94 (17%; 95% confidence interval 14% to 20%) patients in special care units and to 149 (11%; 9% to 13%) of the patients in regular units. The 1873 patients who used drugs received a mean of 5.1 (range 1-20; SD 2.6) different drugs. Patients who received drugs openly used significantly more drugs (mean 5.2; SD 2.6) than did those who got the drugs covertly in food or beverages (mean 4.4; SD 2.2; P value for difference < 0.001). For 95% (226; 4 missing) of the patients, drugs were routinely mixed in food and beverages. Table 1 shows the use of drugs among the patients by ATC-codes and whether they were administered covertly or not.
Table 1 Distribution of type of drugs by method of administration. Values are numbers (percentages) unless stated otherwise
Table 2 shows who decided that drugs should be given covertly and how often the practice was documented. In 54% (119) of the cases, non-compliance was the reason given for administering drugs covertly. Non-compliance means that the patient has refused to take drug or has spat it out. The next most common reason was a problem with swallowing (28%; 62), followed by "to perform the necessary treatment" (10%; 22). We lack data on reason for the disguise of drugs in 22 cases.
Table 2 People who made decision to conceal drugs in food or beverages and proportion of cases documented in records. Values are numbers (percentages)
To find possible explanatory factors for the practice of hiding drugs in patients' food or beverages we did a bivariate logistic regression analysis using patient and ward characteristics as independent variables (table 3). We then entered the variables stepwise into a multiple logistic regression model, entering the variables with lowest P values first. Only variables that showed a significant adjusted odds ratio or had a significant influence on the other variables were kept in the model. As shown in table 3, patient characteristics such as degree of dementia, aggression, and low function in activities of daily living were the strongest explanatory factors for covert administration. Furthermore, patients in special care units had a higher risk of being given drugs covertly. The risk was lower for patients living in teaching nursing homes or in wards with a relatively high staff:patient ratio.
Table 3 Explanatory variables for use of covert administration of drugs
Discussion
Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care 2000;38: 1164-73.
Lindesay J, Matthews R, Jagger C. Factors associated with antipsychotic drug use in residential care: changes between 1990 and 1997. Int J Geriatr Psychiatry 2003;18: 511-9.
Phillips CD, Spry KM, Sloane PD, Hawes C. Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes. Am J Public Health 2000;90: 92-6.
Ruths S, Straand J, Nygaard HA. Psychotropic drug use in nursing homes—diagnostic indications and variations between institutions. Eur J Clin Pharmacol 2001;57: 523-8.
Sorensen L, Foldspang A, Gulmann NC, Munk-Jorgensen P. Determinants for the use of psychotropics among nursing home residents. Int J Geriatr Psychiatry 2001;16: 147-54.
Kow JV, Hogan DB. Use of physical and chemical restraints in medical teaching units. CMAJ 2000;162: 339-40.
Middleton H, Keene RG, Johnson C, Elkins AD, Lee AE. Physical and pharmacologic restraints in long-term care facilities. J Gerontol Nurs 1999;25: 26-33.
Thurmond JA. Nurses' perceptions of chemical restraint use in long-term care. Appl Nurs Res 1999;12: 159-62.
Carstens N. Vet aldersdemente at de f?r legemidler. Sykepleien 1994;88(3): 28-31.
Kuven BM. En engel med sorte vinger. Sykepleien 2000;88(8): 55-7.
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.
Blythe J. Study questions ethics of covert medication. BMJ 2000;321: 402.
Honkanen L. Point-counterpoint: is it ethical to give drugs covertly to people with dementia? No: covert medication is paternalistic. West J Med 2001;174: 229.
Ramsay S. UK nurses receive guidance on covert medication of patients. Lancet 2001;358: 900.
Kirkevold ?, Laake K, Engedal K. Use of constraints and surveillance in Norwegian wards for the elderly. Int J Geriatr Psychiatry 2003;18: 491-7.
Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140: 566-72.
McCulla MM, Coats M, Van Fleet N, Duchek J, Grant E, Morris JC. Reliability of clinical nurse specialists in the staging of dementia. Arch Neurol 1989;46: 1210-1.
Kirkevold ?, Sandvik L, Engedal K. Use of constraints and their correlates in Norwegian nursing homes. Int J Geriatr Psychiatry 2004;19: 980-8.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9: 179-86.
Finkel SA, Lyons JS, Anderson RL. A brief agitation rating scale (BARS) for nursing home elderly. J Am Geriatr Soc 1993;41: 50-2.
Hox J. Multilevel analysis: techniques and applications. Mahwah, NJ: Lawrence Erlbaum Associates, 2002.
Schmidt IK, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med 2002;54: 1767-77.
Nygaard HA, Brudvik E, Juvik OB, Pedersen WE, Rotevatn TS, Vollset ?. Consumption of psychotropic drugs in nursing home residents: a prospective study in patients permanently admitted to a nursing home. Int J Geriatr Psychiatry 1994;9: 387-91.(?yvind Kirkevold, research scholar1, Knu)
Correspondence to: ? Kirkevold oyvind.kirkevold@nordemens.no
Abstract
Several studies have described the use of drugs, including psychotropic agents, in the care of elderly people.1-5 In situations in which psychotropic drugs are prescribed to sedate and control patients, the practice is often called "chemical restraint."6-8 Although the use of psychotropic drugs has been said to erode an elderly person's autonomy and decision making skills by means of sedation,8 covert administration of drugs has been little studied. The concealment of medicine in food or beverages is described in non-scientific articles,9 10 and must be a well known practice among carers in nursing homes, but we found only a few scientific papers that report the practice of covert administration. Treloar et al reported that 71% of residential, nursing, and inpatient units in southeast England at least sometimes administered drugs covertly in food and beverages.11 However, the paper did not report how many residents received drugs in this way. This paper caused some debate in Britain about the ethical aspects of covert administration.12-14 An earlier Norwegian questionnaire study reported that 46% of the wards offering residential care for elderly patients sometimes hid drugs in the patients' food or beverages.15
In Norway the municipalities are responsible for nursing home care. No legislation allows that drugs can be concealed in the patients' food. According to the Act on Mental Health Care and Patients' Rights, drugs can, in some very special circumstances, be given to patients without their consent, but not concealed. The aim of this study was to describe the characteristics of patients and wards relating to the practice of mixing drugs in patients' food or beverages, to explore the reasons for such a practice, and to find out who decided that such an action should be taken. Furthermore, we wanted to examine how this practice was documented in the patients' records.
Methods
The proportion of patients in regular units with a clinical dementia rating scale score of 2 or 3 was 59% (803; 9 missing), compared with 91% (510; 2 missing) in special care units. Drugs were given covertly to 94 (17%; 95% confidence interval 14% to 20%) patients in special care units and to 149 (11%; 9% to 13%) of the patients in regular units. The 1873 patients who used drugs received a mean of 5.1 (range 1-20; SD 2.6) different drugs. Patients who received drugs openly used significantly more drugs (mean 5.2; SD 2.6) than did those who got the drugs covertly in food or beverages (mean 4.4; SD 2.2; P value for difference < 0.001). For 95% (226; 4 missing) of the patients, drugs were routinely mixed in food and beverages. Table 1 shows the use of drugs among the patients by ATC-codes and whether they were administered covertly or not.
Table 1 Distribution of type of drugs by method of administration. Values are numbers (percentages) unless stated otherwise
Table 2 shows who decided that drugs should be given covertly and how often the practice was documented. In 54% (119) of the cases, non-compliance was the reason given for administering drugs covertly. Non-compliance means that the patient has refused to take drug or has spat it out. The next most common reason was a problem with swallowing (28%; 62), followed by "to perform the necessary treatment" (10%; 22). We lack data on reason for the disguise of drugs in 22 cases.
Table 2 People who made decision to conceal drugs in food or beverages and proportion of cases documented in records. Values are numbers (percentages)
To find possible explanatory factors for the practice of hiding drugs in patients' food or beverages we did a bivariate logistic regression analysis using patient and ward characteristics as independent variables (table 3). We then entered the variables stepwise into a multiple logistic regression model, entering the variables with lowest P values first. Only variables that showed a significant adjusted odds ratio or had a significant influence on the other variables were kept in the model. As shown in table 3, patient characteristics such as degree of dementia, aggression, and low function in activities of daily living were the strongest explanatory factors for covert administration. Furthermore, patients in special care units had a higher risk of being given drugs covertly. The risk was lower for patients living in teaching nursing homes or in wards with a relatively high staff:patient ratio.
Table 3 Explanatory variables for use of covert administration of drugs
Discussion
Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care 2000;38: 1164-73.
Lindesay J, Matthews R, Jagger C. Factors associated with antipsychotic drug use in residential care: changes between 1990 and 1997. Int J Geriatr Psychiatry 2003;18: 511-9.
Phillips CD, Spry KM, Sloane PD, Hawes C. Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes. Am J Public Health 2000;90: 92-6.
Ruths S, Straand J, Nygaard HA. Psychotropic drug use in nursing homes—diagnostic indications and variations between institutions. Eur J Clin Pharmacol 2001;57: 523-8.
Sorensen L, Foldspang A, Gulmann NC, Munk-Jorgensen P. Determinants for the use of psychotropics among nursing home residents. Int J Geriatr Psychiatry 2001;16: 147-54.
Kow JV, Hogan DB. Use of physical and chemical restraints in medical teaching units. CMAJ 2000;162: 339-40.
Middleton H, Keene RG, Johnson C, Elkins AD, Lee AE. Physical and pharmacologic restraints in long-term care facilities. J Gerontol Nurs 1999;25: 26-33.
Thurmond JA. Nurses' perceptions of chemical restraint use in long-term care. Appl Nurs Res 1999;12: 159-62.
Carstens N. Vet aldersdemente at de f?r legemidler. Sykepleien 1994;88(3): 28-31.
Kuven BM. En engel med sorte vinger. Sykepleien 2000;88(8): 55-7.
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.
Blythe J. Study questions ethics of covert medication. BMJ 2000;321: 402.
Honkanen L. Point-counterpoint: is it ethical to give drugs covertly to people with dementia? No: covert medication is paternalistic. West J Med 2001;174: 229.
Ramsay S. UK nurses receive guidance on covert medication of patients. Lancet 2001;358: 900.
Kirkevold ?, Laake K, Engedal K. Use of constraints and surveillance in Norwegian wards for the elderly. Int J Geriatr Psychiatry 2003;18: 491-7.
Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140: 566-72.
McCulla MM, Coats M, Van Fleet N, Duchek J, Grant E, Morris JC. Reliability of clinical nurse specialists in the staging of dementia. Arch Neurol 1989;46: 1210-1.
Kirkevold ?, Sandvik L, Engedal K. Use of constraints and their correlates in Norwegian nursing homes. Int J Geriatr Psychiatry 2004;19: 980-8.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9: 179-86.
Finkel SA, Lyons JS, Anderson RL. A brief agitation rating scale (BARS) for nursing home elderly. J Am Geriatr Soc 1993;41: 50-2.
Hox J. Multilevel analysis: techniques and applications. Mahwah, NJ: Lawrence Erlbaum Associates, 2002.
Schmidt IK, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med 2002;54: 1767-77.
Nygaard HA, Brudvik E, Juvik OB, Pedersen WE, Rotevatn TS, Vollset ?. Consumption of psychotropic drugs in nursing home residents: a prospective study in patients permanently admitted to a nursing home. Int J Geriatr Psychiatry 1994;9: 387-91.(?yvind Kirkevold, research scholar1, Knu)