You are called by a worker at a care home. She is concerned about a dementia patient who, despite all non-drug measures being tried, is causing distress to other residents. She asks you to prescribe a sedative to ‘slip into her food’. How should you proceed?
Professor Azeem Majeed: Refuse the request and tell the care home manager
Giving medication covertly raises serious issues. Treatment without consent is only permissible where there is a legal basis. In the scenario described here, giving a sedative to the patient without her knowledge and consent would be a breach of human rights. There is also a risk that she could suffer side-effects. A benzodiazepine or an antipsychotic drug could lead to a fall and result in serious harm.
Covert administration of medication is also a breach of trust on the part of the doctor who prescribed the medication. A formal complaint would be difficult to defend. For these reasons, covert sedation is a practice that doctors should not collude in, and you should refuse to prescribe. You should also discuss the staff member’s request with the nursing home manager. The care home needs to ensure that it is adequately staffed and that its staff are appropriately trained.
If the patient is new to the care home, then her unfamiliar surroundings may be the cause of her agitation. In this case, her behaviour is likely to improve as she becomes more familiar with her new home and the staff. If the increased agitation and confusion are of recent onset, an organic cause such as an infection or side-effect should be excluded. If the problem does not settle, advice should be obtained from the local nursing home support service and community mental health team, for example on whether a ‘best interests meeting’ should be held.
Professor Azeem Majeed is professor of primary care at Imperial College London and a GP in south London
Dr Daniel James
Dr Daniel James: Find out the underlying reasons for the change
The temptation is to give the shortest and most direct answer – no. But this doesn’t help the patient or her carers and you could miss something important. NICE has guidance on emergency sedation. It can be used where the patient or others are at risk of harm; it is not to make patients less disruptive. The guidance stresses the importance of physical observations following sedation, making it safest in an inpatient environment. It also seems unlikely that an assessment of the patient’s mental capacity has been made.
When receiving a call like this you should ask: why now? A patient becoming more disruptive may have delirium and will require assessment. Low-dose sedatives can be helpful to manage delirium in a hospital but should only be used once a cause has been identified and if they are the safest, least restrictive option to reduce the risk to the patient and others. It should also be noted that sedatives can make delirium worse. Otherwise this change may represent a progression of the patient’s dementia. If her care needs are no longer met, this phone call could be the catalyst for considering a move to a home with a higher level of care. The views of the patient and her family should be sought.
There are also safeguarding considerations. Is this the first such request the practice has received from this home? Or are they routinely drugging residents because of a lack of skills or staff shortages? If you are concerned there is a pattern, you should contact the adult safeguarding team.
Dr Daniel James is a GP in Suffolk
Dr Kirsa Morganti
The medicolegal view: Consider options other than medication first
It is not uncommon for a GP to be asked to prescribe medication to alleviate behavioural and psychological symptoms of dementia. Covert administration may be suggested. Prior to prescribing, a history is essential, to ensure a prescription is not issued for the convenience of care professionals. If the patient is not distressed, but the carers are struggling to manage, behaviour management strategies, including increased staffing, may be more appropriate.
Any possible remediable cause for the behaviour, such as pain or infection, should be identified and treated, perhaps with analgesia or antibiotics.
If there is no remediable cause and behaviour management strategies fail, medication may be appropriate. If the patient has capacity, they should be involved in decisions; otherwise, involvement of relatives is appropriate. Information on benefits and risks should be shared. A decision to prescribe should be taken in the patient’s best interests.
Consideration should be given to the formulation, with oral dissolvable tablets or liquid solutions more suitable than tablets or capsules. The possibility of administering medication covertly should be shared with relatives and carers, with the reasons documented and subject to regular review. The lowest effective dose should be prescribed for the shortest time, with review, at least monthly. If no benefit is noted, medication should be stopped. Many behavioural difficulties in dementia are self-limiting and carers may require support through a difficult period.
Dr Kirsa Morganti is a medicolegal adviser at Medical Protection