Challenging pts in Geriatric Psych Unit

[nursnancy, LPN, RN]

I am an LPN working in a Geriatric Psych unit. While most of our pts have dementia in some form, we have recently been getting more pts with paranoid schizophrenia. These pts are "with it" enough to be very suspicious of everything they are given to eat or drink, and yesterday one pt began refusing to eat or drink anything at all. They refuse their meds, thinking we are trying to poison them. There are other problems compounding the situation, too. My unit is a "voluntary" unit, vs. an "involuntary commitment" unit. Therefore, it is illegal on our unit to hold someone down and give them an injection - say of an antipsychotic drug - (except in a situation where the pt has become violent and we have to give them a sedative to protect them and everyone else). Some psychiatrists rounding on the unit tell us to try to sneak meds to the pts in their food, etc. The problem with this is that some of these pts can tell that they've been drugged, which makes them justifiably more pararanoid! I feel pretty comfortable taking care of the dementia pts, but I feel a bit lost and inadequate as to how to deal with schizophrenia pts. Any advice or reading recommendations?

[CoffeeRTC, BSN, RN]

Great question. If its a voluntary unit and they are with it, can you have them sign a contract of sorts to take meds?

[Lawnurse]

Never, never, never "sneak" meds into the food/drink of a patient who has refused the meds.

If an MD wants that to happen, tell him/her you are not interested in committing a battery and being sued by the patient and family.

You could probably be sued for sneaking it into the food of a patient who merely has not consented (as opposed to refused.)

The above poster brought up a hot legal topic - kind of a living will for mental health. The idea behind it is that, while lucid, a patient could sign something agreeing to let you force meds when they refuse.

However, the law does NOT like to let people sign away his/her right to refuse. Hmm...maybe I should be writing my Civil Law & Psychiatry paper on this topic.

I think this goes without saying, but I guess a reminder can't hurt:

"The doctor told me to do it" goes over like a lead balloon in court.

One last thing - I commend the concern the OP has for the geri/psych patients. They need someone like you looking out for them! Keep up the good work. :)

[bargainhound, RN]

The best hand book I have ever read on practicle ideas for dealing with psychiatric patients is:

Effective Approaches to Patient's Behavior

by Gladys B Lipkin and Roberta G Cohen

[nursnancy, LPN, RN]

Thanks for the replies! These are all very helpful!

[danu3]

There is an interesting book "Cognitive Therapy for Delusions, Voices and Paranoia" by Paul Chadwick, Max Birchwood, and Peter Trower. Publisher is Wiley.

Not that you or I are going to give therapy or anything like that. Put some of the stuff in there, potentially can give you some tips and insight.

-Dan

[nursnancy, LPN, RN]

Thanks, Dan! I've ordered the book that Bargainhound recommended, and I'll order "Cognitive Therapy..." as well.

[danu3]

First, I am only a prenursing student. But I am heavily involve in NAMI (National Alliance for the Mentally Ill) and I have a few friends who have paranoia schizophrenia. So my comments are totally nonprofessional, ok?

As you know, you can't convince them the food or drink is not poison. If you try, it gets even worst without the meds.

A few things you could try that are low risk (in terms of not deepening the paranoia) but no gurantee, a shot in the dark:

• Don't dismiss his fear of being poison. Acknowlege his emotion (fear I am assuming). Ask if there is someway you can help. Maybe you can be his food taster if he wants. If he agrees to it, you can take a drink and take some bite of his food (he choose) first. Now he can always say you have an antidote.
  
• Another possibility is to ask if there are anything you can do that is within your capacity to make sure there are no poison (you have to think about this one as it might have a risk of deepening his paranoia because he might interpret it as you agreeing that the food are poison). Let's see... maybe something else... how about saying something like as far as you know, the food and drink are not poison but you are willing within reason to do a few extra things for him so he can be sure (like you being a food taster, or heck, cook things himself, is that possibilt?).
  

As for sneaking meds into food, I agree with previous posters, that is really dangerous. Like you said, lots of them actually can tell. They may be mentally ill, but they are not stupid.

Bottom, he really needs the meds (which is the problem). As the meds weaken the paranoia, the above suggestions will have greater chance of suceeding.

In the mean time, see how much trust you can build if possible. Remember do not think logic, think emotions. That is, see if you can somehow address the emotions behind the paranoia and hopefully that can build some trust.

Oh, here is another possibility (you have to be creative here). You might say something like "it must be horrible to feel that the food or drink is poison." or "I am sorry you think the drink is poison, it must feel awful". They listen and maybe nonchalantly take something from his food and eat it yourself.

-Dan

[danu3]

Thanks, Dan! I've ordered the book that Bargainhound recommended, and I'll order "Cognitive Therapy..." as well.

You're welcome. I have not heard of the one Bargainhound recommended, so I am going to order that too since I do have a few friends who have sz as mentioned before.

-Dan

[danu3]

Oh, since everyone handle these situation differently. Maybe a few principles might help:

• Address the emotion, not the logic
  
• Sow seeds of trust.
  
• Sow seeds of doubt (e.g. you eating a bit of his food and you don't drop dead in front on him)
  
• Encouragment is important (do not criticize). What we consider to be small steps are actually huge steps for the patient. In your example, it could be just the fact he is willing to touch the food with his hand is a huge step. Learning to trust you even a little is a huge step.
  

Most of the "seeds" will not germinate. But all you need is one or two to germinate.

Hope some of it helps.

If you find something that seemed to work, post because I am interested too. If it all fall apart, post, I am still interested.

-Dan