Jones, M

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doi:10.1136/bmj.330.7481.22  2005;330;22-  BMJ  Melvyn Jones     What's the point  http://bmj.com/cgi/content/full/330/7481/22Updated information and services can be found at:   These include:Rapid responses  http://bmj.com/cgi/eletter-submit/330/7481/22You can respond to this article at:   serviceEmail alertingbox at the top right corner of the article Receive free email alerts when new articles cite this article - sign up in the  Notes     http://www.bmjjournals.com/cgi/reprintformTo order reprints of this article go to:   http://bmj.bmjjournals.com/subscriptions/subscribe.shtml go to:  BMJ To subscribe to  on 4 October 2005  bmj.com Downloaded from units would have been subjected to covert administra-tion, because the staff in a special care unit are usuallymore highly trained and aware of the patients’needs,butthe reverse was true. The most likely explanation is thatthe proportion of patients with a severe degree ofdementia and behavioural problems is extremely highin special care units. Hiding the sedative drugs in foodand beverages may in many cases be the only way ofadministering the drugs, because of the non-cooperation of patients who may lack the capacity tounderstand and give consent to drug treatment.Who takes the decision?We are concerned that the physician responsible formedical treatment in nursing homes is not involved inall cases in which it is decided to give drugs covertly.Webelieve that such involvement would reduce thefrequency of the practice, or at least that the practicewould be better documented. A Swedish study showedthat the quality assurance of drug administration waspositively associated with the quality of the communi-cation between the physician and the nurses, and washigher in nursing homes where discussions about drugtreatment took place in the multidisciplinary team.15Nygaard et al have reported that in nursing homeswith a full time physician the use of antipsychotic drugsis lower than in nursing homes where a physicianworks part time.16 Even though these two studies didnot include covert administration, the importance ofan interested physician, cooperating with other healthpersonnel in the nursing home to reduce the use ofcovert administration, might be substantial.ConclusionThe practice of mixing drugs in patients’ food and bev-erages is common in Norwegian nursing homes but ispoorly documented in the patients’ records. The proce-dure for the decision to hide drugs seems to be arbitrary.Contributors: See bmj.comFunding: The research is supported by grants from the Norwe-gian Ministry of Health and Social Affairs (project number16124); the Norwegian Foundation for Health and Rehabilita-tion through the Norwegian Health Association (projectnumber 2001/2/0077); the Lions Club Norway; and theNorwegian Centre for Dementia Research.Competing interests: None declared.Ethical approval: The Regional Committee for MedicalResearch, the Data Inspectorate, and Department of Healthapproved the study.1 Hughes CM, Lapane KL, Mor V. Influence of facility characteristics onuse of antipsychotic medications in nursing homes. Med Care2000;38:1164-73.2 Lindesay J, Matthews R, Jagger C. Factors associated with antipsychoticdrug use in residential care:changes between 1990 and 1997.Int J GeriatrPsychiatry 2003;18:511-9.3 Phillips CD, Spry KM, Sloane PD, Hawes C. Use of physical restraints andpsychotropic medications in Alzheimer special care units in nursinghomes. Am J Public Health 2000;90:92-6.4 Ruths S, Straand J, Nygaard HA. Psychotropic drug use in nursinghomes—diagnostic indications and variations between institutions. Eur JClin Pharmacol 2001;57:523-8.5 Sorensen L, Foldspang A, Gulmann NC, Munk-Jorgensen P. Determi-nants for the use of psychotropics among nursing home residents. Int JGeriatr Psychiatry 2001;16:147-54.6 Kow JV, Hogan DB. Use of physical and chemical restraints in medicalteaching units. CMAJ 2000;162:339-40.7 Middleton H, Keene RG, Johnson C, Elkins AD, Lee AE. Physical andpharmacologic restraints in long-term care facilities. J Gerontol Nurs1999;25:26-33.8 Thurmond JA.Nurses’perceptions of chemical restraint use in long-termcare. Appl Nurs Res 1999;12:159-62.9 Treloar A,Beats B,Philpot M.A pill in the sandwich:covert medication infood and drink. J R Soc Med 2000;93:408-11.10 Blythe J. Study questions ethics of covert medication. BMJ 2000;321:402.11 Honkanen L. Point-counterpoint: is it ethical to give drugs covertly topeople with dementia? No: covert medication is paternalistic. West J Med2001;174:229.12 Ramsay S. UK nurses receive guidance on covert medication of patients.Lancet 2001;358:900.13 Kirkevold Ø, Laake K, Engedal K. Use of constraints and surveillance inNorwegian wards for the elderly. Int J Geriatr Psychiatry 2003;18:491-7.14 Hox J. Multilevel analysis: techniques and applications. Mahwah, NJ:Lawrence Erlbaum Associates, 2002.15 Schmidt IK, Svarstad BL. Nurse-physician communication and quality ofdrug use in Swedish nursing homes. Soc Sci Med 2002;54:1767-77.16 Nygaard HA, Brudvik E, Juvik OB, Pedersen WE, Rotevatn TS, Vollset Å.Consumption of psychotropic drugs in nursing home residents: aprospective study in patients permanently admitted to a nursing home.Int J Geriatr Psychiatry 1994;9:387-91.(Accepted 22 September 2004)doi 10.1136/bmj.38268.579097.55What is already known on this topicThe practice of covert drug administration in foodand beverages is well known in residential andnursing homes, but no prevalence rates existNo information is available on which patients areparticularly subjected to covert administration oron the procedures for documenting the practiceWhat this study addsIn Norway, 11% of patients in regular nursing homeunits and 17% of patients in special care units fordementia were covertly administered drugs at leastonce, and in 95% the practice was routinePatients with severe cognitive impairment, reducedfunction in activities of daily living, or aggressivebehaviour were more often subjected to covertadministrationThe practice of covert drug administration waspoorly documented in the patients’ recordsWhat’s the pointPoints, points? I am running to time and thinking, “Can I getsome points in this consultation?” After all, in the new world ofgeneral practice where points make prizes, dealing with theproblem is no longer enough. The new UK GP contract haschanged the interaction with patients by quantifying (andrewarding) certain clinical activities, particularly datacollection.My eyes quickly scan the prevention screen of thecomputer and see that we have no smoking status on this man.By this stage he has put his coat back on and is nearly at thedoor.“Do you smoke?” I ask quickly.He looks a bit puzzled and fumbles for his cigarettes: “Yes. Doyou want one?”Melvyn Jones lecturer in general practice,department of primary careand population sciences,Royal Free and University College MedicalSchool,London (m.jones@pcps.ucl.ac.uk)Primary care22 BMJ VOLUME 330 1 JANUARY 2005 bmj.com on 4 October 2005  bmj.com Downloaded from 

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