Concealing Medication: A Case Vignette

Provided by Jay Luxenberg, MD

A 78-year-old nursing home resident with mild dementia and a long history of schizophrenia controlled with an oral antipsychotic was given a trial of antipsychotic tapering and discontinuation by her primary care physician. Several months later she began demonstrating increasing paranoia and delusions. The physician reordered the antipsychotic, but she had begun refusing to take medication due to her suspicions about the healthcare system and medication in general. This included her medication for co-existing medical conditions such as hypertension.

Her behaviors associated with her delusions and paranoia worsened to the point where the nursing home felt they could no longer safely take care of her. Her physician arranged transfer to a geropsychiatric acute hospital. In the hospital, an antipsychotic was administered mixed into her food. Her family gave consent for this, as she was considered to lack capacity for medication consent. On this regiment of concealed antipsychotic she improved and was considered ready for discharge from the hospital. Her original nursing home felt that they could not administer medication hidden in food, and alternative discharge sites were sought. Some residential care facilities for the elderly (RCFE) that specialize in dementia care offered admission and were comfortable with hiding the medication. Her physician felt this was not in compliance with the regulations that govern RCFEs. After discussion with the psychiatric staff at the hospital, a long acting parenteral antipsychotic was started, and efforts intensified to get her to take her oral medications again. That succeeded, and she was able to return to her original nursing home without the need to hide the medication.

The question of the role of concealment of medication was extensively discussed – is it acceptable ethically? If so, are there regulations that preclude it in settings such as nursing homes or RCFEs?

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