When residents refuse to take their medications.

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.

In short, medication nurses may need to be treated differently than other ward staff in order to have time to develop the necessary special relationships with the patients. It may, in fact, be necessary to relieve the medication nurse from other routine nursing tasks so that the time for this is available. Responsibility for any tasks that might divert the nurse from this primary goal may have to be shifted, perhaps, to another staff member. Furthermore, this will help insulate the medication nurse from being associated by the patient with some of the more unpleasant tasks that nursing staff has to perform. Realizing the importance of solving this problem, the nursing staff has attempted to accomplish this to the extent possible.

Obviously, some Socializers and medication nurses will be far more effective in these roles than others. The personality, appearance, and manner of the Socializer and medication nurse are all factors which may affect medication compliance. It is also important to recognize that, when one medication nurse or Socializer is particularly effective with a specific patient, it is logical to continue using that individual in distributing medication to that patient.

Persistence is another factor that can increase a patient's willingness to take medication; one may actually have to "wear down" the patient's resistance. If the patient tends to be combative, however, the medication nurse must be very wary of eliciting an aggressive or agitated response. It should also be noted that what appears to be a rejection of medication may in fact be simply an inability to understand. At times, "No" may mean something other than "No, I don't want the medication." It may mean, "No, I don't want you to involve me in any intrusive treatment," "I don't want you to hurt me in any way," "I want to be left alone," or simply, "I am uncomfortable and I will say no to anything without understanding what is being offered to me." An appropriate response takes thought and some knowledge of the patient's past behavior or comments.

Also, it has been noted that a "show of force," consisting simply of a few people standing around the patient, will sometimes encourage the patient to be compliant and agreeable. In fact, it sometimes seems on occasion that the addition of the Socializer enhances the patient's medication compliance simply because there are two staff members, rather than just the medication nurse, in attendance.

There are times when offering the patient a choice of administration method may increase positive response to taking medication. While there may be few choices that the patient can actually make in this regard, he may at times be offered either juice or water to drink afterwards. Or, allowing the resident to make the choice of treatment -- e.g., oral laxative or suppository/enema -- may also be realistic in some cases.

Rewards

Another strategy to enhance medication compliance incorporates theories of behavioral psychology. When a behavior is followed by a reward or reinforcement, the probability increases that the behavior will occur again. Thus, if socialization is rewarding to the patient, staff should continue the period of socialization after the patient takes the medication. If, however, the patient refuses the medication or behaves in an inappropriate manner (e.g., with verbal abuse or a physical assault), socialization should be guarded against to avoid seeming to reward -- and thereby reinforce -- the patient's inappropriate behavior.

Reinforcers other than socialization may be offered following the patient's taking the medication in a compliant manner. For example, a friendly smile, a food treat, or anything else that elicits a positive response may increase future medication compliance.

Mood Enhancement

It has often been noted that once a patient is in a bad mood, it is difficult or impossible to modify it. At these times, predictably, the patient will often refuse medication. Prior to dispensing the medication, the medication nurse may choose to compliment the patient, joke with him or her, provide the patient with an opportunity to return to his or her room or to take a very short walk with the medication nurse. Not only may this enhance the patient's willingness to take the medication, any improvement in the patient's mood may ease other aspects of nursing care, as well.

Conclusion

Rather than initiating a battle of wills or an angry, hostile encounter, using specific techniques to reinforce patients' agreeable behavior is strongly encouraged in improving medication compliance. Special efforts along these lines are obviously worthy of staff time and attention. Methods that have proven effective incorporate socialization and other reinforcement techniques applied consistently, gently, and with the patient's best interests at heart.

Kathleen S. Mayers, PhD, is a counselor in the Geropsychiatric Medical Unit, Western State Hospital, Tacoma, WA.