Expert: Mary Gordon - 4/26/2010

Question
This is the second time I have turned to you for information.  I thank you for the excellent advise you gave us before concerning getting my mother in law to eat.  The staff has done all the suggestions but to no avail.  She still eats very little if any and is now refusing to take her medications for the staff.  They have tried every thing they know and the doctor now advises them to just try to get her to take the most beneficial ones.  She spits the medicine out and is hitting them when they try to get her to take it.  My question is "where do we go from here?"  What can we do?

Answer
Hi Deidra

I think they are taking the right approach in that the staff are trying to concentrate on the most important meds. After all, she has a terminal disease (her dementia) and a limited life span no matter what medication she takes - or doesn't take. Given that perspective, many medications won't seem that important in the bigger picture.

I don't know what they have tried or how much she understands of what is going on. If she is aware of food and shows any preferences, bribery sometimes works - such as offering her a small snack she likes, a piece of cookie, or a bite of ice cream, with one pill. When she's finished that, offer another treat ... with another pill. I am hoping they are not just handing her six pills at once and expect her to take them all happily.

If she won't take a pill, check with your doctor or pharmacist to find out if the med is available in a different formulation. Some medicines come in a liquid form. Others come in a cream or gel that can be rubbed on the skin. And some are available as a patch.

Another thought is to hide the medication in food. Whether your loved one is resisting taking her meds, or has simply forgotten how, try offering them to her hidden in a soft food such as apple sauce, yogurt, pudding, dessert baby food, fruit preserves, or jelly, one pill per teaspoonful. She may just swallow the food, pill and all.  I've even heard of meds being hidden in the bottom of  piece of chocolate, like Stovers or Whitmans.

If hiding a whole pill in food doesn't work, check with your *pharmacist* (not doctor) about which pills can be crushed, and which can be dissolved. (Some pills should *not* be crushed, and some should not be dissolved. Be sure to check first.) Also, be sure to ask your pharmacist whether any of the pills taste horrible.

If the pill doesn't taste bad, you have lots of options. If it can be crushed, caregiving staff can try just mixing it with whatever kind of food she will eat, from purred meats to ice cream. Staff can put crushed pills into smoothies or other drinks that can be consumed with a straw.  "Simply Fruit" type jam can work as a good mix for crushed pills. Many people with dementia will lose a lot of their sense of taste, but sweet is the last to go.

Pills that can not be crushed or chewed can often be dissolved in liquid (again, checking with a pharmacist first). If the pill doesn't taste bad, try dissolving it in hot chocolate or herbal tea sweetened with honey. Hot liquids tend to dissolve pills more quickly but you can try warming a sweet fruit juice, dissolving the pills, and then cooling the drink again.

I've heard of dissolving pills in strong-set  Jello, like  Jigglers. The example I read described one making the jello right in 7 day pill container - they poured the hot mixture right in on the pills, which then dissolved into the jello. They then put the whole box in the fridge and every day popped out a jello square to give their loved one.

Pills that taste really awful require additional steps. Separate the really bitter ones from the others and mix them with a *tiny* bit of plain vanilla yogurt, mixed with a little sugar if that helps. The reason for using a *tiny* bit of yogurt is to make sure she gets all of the medicine in the first bite. To make sure that the bitterness doesn't stay in her mouth any longer than necessary, immediately follow up with some more yogurt or ice cream or whatever she likes best. If she will have some, I'd follow up with a drink to flush away any remaining taste.

For bitter pills that cannot be crushed but can be dissolved, dissolve the pill into a tiny glass like a shot glass, add a *tiny* amount of water or apple juice, let it dissolve, then add a teaspoon or two of yogurt or applesauce. Do not add the pill to a large amount of any food because, as above, if your loved one doesn't eat the entire amount, you have wasted that pill, *and* adding them to the smallest amount of food means your mother in law will only have to take a single swallow.

Caregivers of Alzheimer's patients are not the only people who have trouble getting loved ones to take medicines. There are "compounding pharmacies", licensed and regulated by their respective state boards of pharmacy, that may be able to help you and your loved one's doctor come up with ways to simplify giving her meds. Compounding pharmacies can help by, e.g., combining several medications to simplify administering them; preparing the medication in cream, liquid or other form that the patient can easily take; and/or adding flavors to make them more palatable. To find a compounding pharmacy in your vicinity, go to:

http://www.iacprx.org/site/PageServer?pagename=lookup_survey

Hope this helps.

Looking ahead, you may want to look into palliative care and hospice options, where the focus is no longer on curative or preventative care, but on patient comfort. In other words, you let go of the medication and treatment war, and let her be serene and comfortable, with the understanding that you are going to keep her happy and out of pain, and not fight wars you cannot win - particularly those which may no longer have a point.

You may or may not be ready for that approach as a family. Everyone is different. It has to be about quality of life first and foremost. Even just doing the research may make you feel better in that you have some thoughts about what might come next, and have discussed the options with each other.

Thinking of you. It really is a heartbreaking disease.

Mary Gordon