We naturally chew food before swallowing, but tablets and capsules require a complicated, conscious mechanism to over-ride the need to chew and the gag reflex, designed to eject foodstuffs that are not adequately chewed.
To ease swallowing of medication, some people tip their heads back, opening the airway as during cardiopulmonary resuscitation. This increases the chances that medication will “go down the wrong way” (aspirated). When tablets and capsules are inhaled, they can cause breathing difficulties, lung infection and lung tissue death.
Difficulty in swallowing – dysphagia – has been diagnosed in 35% of people aged over 50 and frequently appears after stroke and in older people with dementia, Parkinson’s disease and many other conditions.
People with dysphagia have an even greater risk of aspiration of medications. Research has found some 60% of them have trouble swallowing solid tablets and more than half had residue remaining in the throat after swallowing, 17% had material that sat above the airway while 11% aspirated the medication (Carnaby-Mann and Crary, 2005).
To overcome difficulties in swallowing solid medication, many patients and carers crush tablets or open capsules. This may alter the therapeutic effect of the drug; an insufficient dose may be administered or toxic dose-dumping occur. Given that medicines are the mainstay of medical management, the inability to swallow medicine safely is cause for concern.
During my first 10 years as a community pharmacist, I was consulted by many patients who found it difficult to swallow medication, despite not having been diagnosed with swallowing difficulties. This is not surprising given that the vast majority of swallowing assessments consider food or liquids that, as mentioned above, are part of a different swallowing process.
We have been working for the past 18 months on a screening tool to assess swallowing problems associated with solid medications. After training, this tool could be used by nurses, pharmacists, speech and language therapists and others in primary and acute care.
The tool aims to minimise the impact of swallowing difficulties on treatment by ensuring that medication continues uninterrupted when dysphagia comes on suddenly, for example in stroke patients. It also aims to maximise the safe use of medicines in the community and in hospital by accurately setting up the threshold of the size of the medication that the patient can safely swallow.
Dysphagia management is not easy and requires the combination of different disciplines and a multiprofessional approach. This tool will be another step forward in the management of dysphagia. NT
Jose Manuel Serrano Santos is dysphagia research pharmacist at Medicines Management Research Group, School of Pharmacy, University of East Anglia; Julie Cichero is senior research fellow and honorary research consultant, School of Pharmacy, Unversity of Queensland, Australia
Carnaby-Mann G, Crary M (2005) Pill swallowing by adults with dysphagia. Archives of Otolaryngology Head & Neck Surgery; 131: 970-975.