When residents refuse to take their medications - Nursing Care

Nursing Homes, April, 1993 by Kathleen S. Mayers

An angry, disoriented, hostile elderly resident swatting away a medication cup or grimly clamming up and turning away -- a situation encountered routinely by any nursing home staff trying to provide needed medication. Here are some suggestions for easing the situation.

Any resident with dementia or psychiatric illness who refuses oral medication poses a major problem to the staff. Many residents are confused and disorganized, do not comprehend the need for medication, and cannot recognize that what is being provided to them is, in fact, medication. And if the taste is unpleasant, the resident, much like a child, may simply refuse to "open up." There are, fortunately, several methods to increase the elderly resident's willingness to accept oral medication even when psychiatric illness or dementia interferes with the process.

Even though many residents function in an extremely deteriorated and regressed manner, and may not be able to communicate well or understand their environment, it is still very often the case that they maintain some social graces. Residents can often "read" expressions and respond with smiles, curiosity, anger or fear. Residents generally enjoy social approaches by staff, will respond favorably to compliments and social stimulation, and may retain a kind of social intelligence and awareness long after problem-solving, reasoning, and ability to articulate their thoughts have been lost.

In a situation in which a resident retains some cognitive skills and verbal abilities, staff may talk with the resident about the benefits of the medication, encourage the resident to accept appropriate treatment, and listen to the resident as he explains why he does not want the treatment. They can often provide information in a clear and uncomplicated manner.

However, the non-verbal or minimally verbal resident is not likely to benefit from such approaches. Nevertheless, the resident's remaining social responsiveness may still be useful as a means of increasing his medication compliance. Even though the resident is routinely responding to nursing intervention, routine hygiene tasks and so forth with a resistant, combative attitude, often displayed through hitting, kicking, grabbing, spitting or verbal assault, that same resident often obviously enjoys it when a staff person approaches, talks in a soft, calm tone and even holds the resident's hand or touches him affectionately on the shoulder.

Attempting to build on this, our facility has developed several medication compliance strategies emphasizing social interaction. Some involve role-playing, and some change traditional roles.

The Socializer

One of our compliance strategies was to select a student to serve as a "Socializer." The patients had had no negative history with this individual or developed any unfortunate associations with him; in fact, the student had previously been involved with them in pleasurable activities, such as recreational outings, helping patients to eat, wheeling patients off the ward, and participating in brief verbal interactions with them. In his new role, the student Socializer was to remain with the patient until prescribed medication had been accepted and administered.

The student approached each patient a few minutes before the medication nurse was scheduled to arrive. The task assigned to the student was to engage the patient in a social interchange, whether through dialogue, hand holding, mutual smiling or conducting a monologue about pleasant aspects of the day -- the warm sun, the attractive clothing worn by the patient, the patient's beautiful smile, enjoyable outings scheduled later in the day, or other positive features of the environment. When the medication nurse arrived, the student was to remain with the patient during the administration of the medication.

The idea behind this, of course, was that this period of social contact may improve the patient's mood, provide social validation to the patient and communicate that the patient is liked and regarded positively. The message is that pleasant and appropriate behavior is expected of the patient, part of which may well be improved medication compliance. While the patient might recall that he or she had previously behaved in an aggressive, hostile, rejecting manner with the medication nurse, the hope was that he or she might not want to display this behavior in the presence of the Socializer.

As it turned out, this strategy worked, to some extent. Several patients who previously had consistently and totally rejected medication raised medication acceptance rates to approximately 50%. In some instances in which this strategy failed, the patient had already started the process of fighting with staff about other issues, e.g. dressing, grooming, or hygiene, and the patient wanted no contact with anyone under any circumstances, even the Socializer.

Favorite Nurse

In further evaluating patients' medication compliance, it rapidly became apparent that the personality of the medication nurse and the relationship between the nurse and patient had an impact on the likelihood of the patient accepting or rejecting medication. As with the Socializer, a pleasant, calm and patient manner, a smile, an approach which incorporated persistence, all tended to facilitate an attitude of compliance with the medication regimen. Indeed, this relationship proved so crucial that it merited reconsideration of some of the medication nurse's routine functions.