Tips for helping Alzheimer's patients take their medicines

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Our loved ones may not be able to tell us something is wrong, and may react negatively to taking pills for a number of different reasons. The first thing to consider is whether they may be having an adverse reaction to a medicine. Cholinesterase inhibitors (aricept, razadyne, exelon), for example, often cause nausea, abdominal pain from gastrointestinal effects, anorexia, or agitation. Or the loved one may be in pain -- from arthritis (which may limit the range of motion your loved one can make with her arms), constipation, poor oral care and resulting pain in the gums or teeth, poorly fitting dentures, or a urinary tract infection, for example. Or she may feel sick, from having stomach flu, a sore throat, or even a cold that won't let her breathe through her nose. You may even be offering the medicine in a place that is upsetting to your loved one. If you're in the bathroom, she may be distressed by the reflections in the mirror, for example. There may be too much noise, perhaps from a TV or radio, or playful children. Or she may have trouble recognizing the pills, perhaps from problems with visual agnosia.

If you have ruled out problems such as these, your loved one may be forgetting how to take medicines, or may be resisting taking them for some reason. Sometimes, they simply forget that it's been a long time since they took their pills. Caregivers may have to be very, very creative to get our loved ones to take the medicines they need. What is successful may vary from patient to patient, and also change as the dementia progresses.

Suggestions from experienced caregivers:


1. Providing cues

Initially, we can simply offer the pills to our loved ones, and watch to make sure that all of the pills are taken. However, as the Alzheimer's progresses, our loved ones may forget how to take pills.

If you place the pills in your loved one's hand and she simply holds them and doesn't seem to know what to do with them, try giving verbal cues at each step: "It is time to take your medicine. Here is a pill. Put the pill in your mouth; now take a sip of water; now swallow the pill."

Remember to offer lots of praise for doing the things your loved one can do, and never scold for being unable to do something. And do not rush your loved one -- give her plenty of time to figure out what to do, and how to do it.

Your loved one may need verbal cues combined with physical cues, such as touching the hand that is holding the pill and then touching her mouth, perhaps with you showing her what to do. If those fail, try holding the pills to her lips and when she opens her mouth, place them in her mouth and then hand her a drink. She may do better if you put the drink in a mug that's easy to hold, or use a straw. She may prefer a sweet fruit juice, rather than water.

When holding the pills to her mouth no longer "cues" her to open her mouth, you may have to remind her to open it. As your loved one develops problems with swallowing, she may need assistance, such as stroking her throat.

When that is no longer successful, try putting the pills into small amounts of a favorite food. Usually, caregivers have reported having the most success with sweets -- jelly, yogurt, apple sauce, fruit preserves, smashed bananas with a little sugar, dessert baby foods, ice cream, or pudding.

If the medicine comes in a liquid form, you can try using a syringe (*without* a needle!!!) to place it in your loved one's mouth.


2. Make it a non-event

Unfortunately, some Alzheimer's patients can be stubborn about taking medicines, or suspicious as to why the caregiver is offering them. Pill time can become very distressing to both the patient and her caregiver.

If your loved one resists, don't make it into a battle! Come back in five minutes and perhaps her attitude will be different if you try a new approach.

Stop announcing that is "meds time". Lighten up -- be smiling and playful when you offer the pills. This is a happy thing, a fun thing, a wonderful thing to do.

Offer one or two pills at a time, rather than all at once. Discuss the timing with your loved one's doctor to see how you can split up the meds throughout the day. Please note, some meds should not be taken with others. Also, check to see if the meds need to be given with food or without food, or an hour before a meal or after a meal. Some meds are absorbed better when not given with food. Others need to be given with food, to prevent nausea. Also, find out whether there are certain foods that should be avoided. (For example, grapefruit is not compatible with a number of different medications.)

Have a schedule? If not, make one. Alzheimer's loved ones often do better on a schedule. Eating, sleeping, grooming, and pill-taking on a daily schedule provides structure for them and helps them relax.


3. Make a game of it.

One caregiver reported success by making a game of taking the pills. She put the pills in her loved one's hand and would say "Bet you can't take all three at once." Her loved one enjoys proving her wrong, and so she makes a big deal of it when her loved one is successful.

Another said: One thing that has worked is I will ask Mom to take Dad his little cup of pills and a glass of water. When she has done that, I give Mom her pills and water and say, "Now Dad has his pills and you have yours. Go ahead and take them." Sometimes I pretend that I have to take meds too and will hold my own little pill cup when I give Mom hers. "Let's take our medicine now. I have to take mine, too." (You can buy empty pill gels if you don't need to take any medicines or supplements, or you can "take" M&M's or other small candies.)

Keep a sharp eye out ... some loved ones will hold the pills in their mouths, and then spit them out after you've left the room. They may not actually be doing that to fool you ... they may not understand that they need to swallow the pill. As it starts to dissolve in the mouth, it tastes bad, so they spit it out.

Put on a "white smock" and play nurse with your loved one. Older people are much more likely to respond well to authority than to coercion from family members, so "playing nurse" may just get your loved one to respond in a positive way. And if your loved one fusses a little at you, say, "I'm just the nurse, your daughter will be back after you've finished taking your pills" (with a smile on your face, of course!)

Your demeanor when you offer pills, food, or drinks means more than to your loved one than what you are actually doing. Approach your loved one with a big smile and say something playful, like, "Time for your closeup Ms. DeVille" ... or come in humming Mary Poppins "A spoonful of sugar makes the medicine go down". Also call your loved one by her given name -- first name *and* last name, instead of "Gram".

And speaking of authority:


4. Get a note from the doctor

Ask the doctor to give you a brief note, written on his prescription pad: "Loved one's name: Take your pills! Thank you. Dr. So&So"

One caregiver said: Reasoning is usually a waste of time. Trying to explain to them why they have to do something is pointless. If there was a medication that my Gram flat out refused to take, I would announce (nicely) that I was going to call the doctor and ask if there is something else he could provide instead of what she has. Using a bit of guilt often convinced her to "take her meds" without having to bother the doctor. "Oh, just give it to me," my Gram would say.


5. Try bribery

Get your vitamins out, and take them along with your loved one, saying as you go, "Let's take our vitamins together so we can be strong and healthy, then we will go do something fun!"

Offer your loved one 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. Don't hand her six pills at once and expect her to take them all happily.


6. Try a different formulation

If your loved one simply 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.


7. Hide the medicine in anything edible...

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. (By the way, if you, yourself, have trouble swallowing large pills, they are much easier to swallow in a spoonful of yogurt.)

And for the ultimate in sneaky, one caregiver said: "I had worked in a nursing home some years back, and had some patients that refused their meds. We would hide them in a piece of chocolate, like Stovers or Whitmans. We put it in the bottom of the candy so that they wouldn't see it."

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, you can try just mixing it with the top layer of food on your loved one's plate. That way, if your loved one doesn't finish the entire helping, your loved one has gotten her full dose before becoming full, and the food is there for you to try again a little later on.

One wife loved Dannon Frusion smoothies. Her husband found that putting the crushed pills into the smoothie a couple of hours before dinner worked best. His wife particularly liked drinking from fast food cups with a top and straw. Another caregiver liked to make a little "well" in ice cream in a cone, put crushed pills into the well, and then pack ice cream all around. Yet another had success with pie -- she peeled back the top layer, scattered the crushed or dissolved pills over the filling, and then replaced the top layer.

One caregiver mentioned, "For a year about two years now I have been crushing my dad's and stepmom's pills and mixing them into a single spoonful with 'simply fruit'. I can change up their pills and they never get upset with a new med showing up in their pills. A lot of their taste sensation is gone, but sweet is the last to go so I can usually mix even bitter pills and not get a bad reaction to the spoonful of meds. When I started it with my stepmom (who was suspicious of pills at the time) I told her the doctor said she needed something sweet before each meal. That explanation seemed to work."

Pills that can not be crushed or chewed can often be dissolved in liquid. 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.

One very creative caregiver reported, "Our best effort was the Jello. It was quite ingenious. You make Jello liquid, make it a little strong, more like Jigglers. Pour the jello liquid into the 7 day pill container (the little plastic boxes all in a row), and shove the pills in. If you get it right (you'll learn), the pills dissolve into the jello. Put it in the fridge, and let it set. Then every day you take out the box, and carefully run a fork or butter knife around the edge. Sploop! A little cube of flavored drugs pops out, and that's what I'd give her to eat before she got her meal. 'Eat your jello, and I'll give you breakfast!' said in a cheery tone usually got the job done. Stir some sugar into it, too. They love sugary stuff. They hate pills."

You may be able to hide a slightly bad taste by diluting the crushed or dissolved med in a larger volume of food. However, some pills have a *horrible* taste, and your loved one will refuse to take more than one or two bites even when the pill is mixed with a large amount of food or liquid. If she eats part of the food before deciding she doesn't like it, you won't know how much medicine she's consumed. You may want to take a tiny taste yourself before offering it to your loved one, to see if this will work. (Ask your doctor if it is safe for you to do this before trying it, however!)

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 your loved one gets all of the medicine in the first bite. To make sure that the bitterness doesn't stay in his/her mouth any longer than necessary, immediately follow up with some more yogurt or ice cream or whatever your loved one likes best. Then have your loved one drink some sort of liquid to try to flush away any remaining bad taste. If the medicine is to be given with a meal, immediately feed your loved one. After the liquid or meal, brush your loved one's teeth, tongue, and the roof of the mouth.

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 loved one will only have to take a single swallow.

If your loved one is suspicious that you are lacing her food with medicine, calmly show her all of her meds in a small cup at the end of the table. Of course, you do this after you have already put all of her meds in her food ... the "decoy" pills simply make her think you haven't meddled with her food. Then, if there is a pill that cannot be put in food, or crushed or dissolved, offer that one pill after she has eaten, telling her she has been so good, she only has to take one.


8. Talk with a compounding pharmacy

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


9. Have a Plan B

What works today may not work tomorrow. Be flexible, and understanding. And do your best to keep a sense of humor about it!