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Practice Comment

'Inability to swallow tablets is common and cause for concern'


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

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Readers' comments (11)

  • patients who have difficulty swallowing tablets can have their medication reviewed by the doctor and the pharmacist so that syrups/dispersibles can be dispensed.

    With a bit of common sense this isn't really a cause for concern at all.

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  • As a former nurse, I have been fighting for long to get my doctor to prescribe liquid medication for my husband after having a stroke and I can’t ever convince him. Common sense doesn't apply this days as much as budget and £££ do.
    I think that the right assessment would override any argument between patients and other professionals and would definitely help patients with swallowing problems.

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  • re the above, I have prepaid prescription card & I asked my doctor for the "caplets" as they are called & the dispensary told me that as I was not paying for my Prescription?! I could only be given the tablets & would have to cut them in half! The cost of the caplets is peanuts in the scheme of things when considering the cost of some of my other meds! But really swallowing is such a big issue with many patients and as pointed out crushing tablets or opening capsules alters their properties and absorption so it needs to be addressed

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  • you can easily get soluble paracetomol.

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  • Aside from the fact that soluble paracetamol may not be suitable for all patients (sodium content for example), if we widen the discussion to include all medicines then the variety of dosage forms associated with paracetamol are not always readily or practically available.

    The tool outlined in the article could play a useful part in supporting patients with swallowing difficulties and perhaps at some point down the line provide evidence to the pharmas that dosage form shape and size is something they should pay more attention too.

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  • One might suspect that the complacency demonstrated in some of these comments may in part be a cause of the problem?

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  • Is the problem not less to do with what alternatives are available and more to do with identifying when and which of the alternatives are required for individual patients? A tool to speed up ward rounds and reduce errors doesn't seem like a bad idea in principle, so long as this proposed tool does achieve that.

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  • Identifying what is best for patients is one thing but having the means to address their needs is another. A tool such as this could be very beneficial in supporting patients. It will be interesting to read Dr Serrano's research findings as his work on developing this tool continues.

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  • I find it surprising how often medicines are prescribed without assessing before (or afterwards) how well the patient is able to manage their medication regime. I think this tool will be very useful along with a comprehensive look at how patients manage their medicines- not just thinking we know how they cope. This will lead hopefully to quality of life improvement generally - including health and also in the long term cut wastage on unuseful forms of medicines not taken and increased hospital admissions

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  • medicines are often prescribed that have alternate formats eg liquids or soluble intstead of tablet format. I think the reasons why the easier format is given is mainly a cost issue as the liquid formats are apparently often twice as expensive. Some medicines are not yet available in formats other than tablets.
    It is down to us as a profession to apply gentle persusion with evidence based nursing to make this happen.
    Maybe then things will change and patients find taking medicines less difficult.Empower the patient

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