Swallowing difficulties

Case scenario

Gary is 70 years old and is diagnosed with stage 3 Parkinson’s disease. He is currently living alone since the death of his wife in 2015. He complains of difficulty swallowing medications whole and is looking for recommendations to help with this. He consistently feels the sensation of food getting stuck in his throat/chest and has occasionally choked on his medicines. He has no issue with swallowing foods with smooth texture; he asks whether he could crush his medication and mix them with food. He has hypertension, hyperlipidaemia, and depression. His current medications include levodopa with carbidopa 200 mg/50 mg controlled-release, atorvastatin 40 mg, ezetimibe 10 mg, irbesartan 300 mg and mirtazapine 45 mg.

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Introduction

The oral route is considered the most convenient method of drug administration, with more than 70% of medications being administered by mouth.¹ More than 60% of active pharmaceutical ingredients are formulated as solid oral forms such as tablets and capsules.² Medication swallowing difficulties refers to having problems swallowing medication with or without dysphagia, particularly tablets and capsules. Dysphagia refers to the difficulty in swallowing oral content, including food and/or liquid, as a result of a physiological impairment in the swallowing process.³ This article aims to create awareness of the considerations around medication swallowing difficulties, and the important role that pharmacists should play in providing appropriate recommendations to individuals who experience medication swallowing difficulties.

Prevalence

In an Australian study of 152 nondysphagic adult participants, 32% reported some degree of difficulty swallowing tablets and capsules, and 55% experienced difficulties with swallowing medications at some point in their life.³

Swallowing solid medications

Swallowing solid dosage forms whole goes against the innate chewing reflex. This may trigger the gag reflex in some individuals when the tablet or capsule touches the tongue. Successful swallowing of a solid dose depends on an individual’s ability to overcome their chewing and gag reflex.⁴ Swallowing tablets and capsules without chewing is a learnt skill that can be taught.⁵

Contributing factors

The physical characteristics of solid oral medications can impact an individual’s ability or willingness to swallow them. Smaller capsules tend to be easier to swallow than larger ones e.g. capsule sizes of 000 and 00.³ Individuals may find tablets or capsules more difficult to swallow when the sum of the length, width, and depth of the dosage form is larger than 21 mm.⁶ There is a preference for tablets that are white and coated.⁷ Small tablets that are round-arched and large tablets that are oval are preferred.⁷ Tablets and capsules that are too small in size may also be difficult to swallow as some individuals may be unable to feel them once they are in the mouth.8 Rough textures, irregular shapes and unpleasant tastes or smells are among other factors that may influence an individual’s acceptability of solid oral medications.^8,9,10 

Some individuals may have a psychological aversion towards swallowing medications due to a past traumatic event e.g. choking episodes associated with swallowing tablets and capsules.^3,10 If the event occurred in childhood, it may continue into adulthood if left unaddressed.¹⁰

Females may be more likely to experience medication swallowing difficulties due to a shorter interval between swallows, and a smaller volume in each swallow compared to males.¹¹ Age is another contributing factor to swallowing difficulties where swallowing flow and volume capacity decreases as we age.¹¹ Prolonging the swallowing process may cause solid medications to disintegrate in the mouth releasing a bitter taste which may further contribute to the difficulty with swallowing them. Older people are more likely to have dysphagia due to age-related functional impairment and the increased likelihood of medical conditions such as stroke, Parkinson’s disease, or xerostomia (dry mouth).¹⁰

Signs and symptoms

Some signs and symptoms of medication swallowing difficulties include coughing, choking and gagging during or right after swallowing the tablet or capsule. A sensation of the tablet or capsule in the throat or feeling anxious during or before swallowing the tablet or capsule may occur.¹⁰ Some individuals with medication-swallowing difficulties may be asymptomatic,¹² therefore an absence of signs and symptoms may not necessarily rule out any risk of medication swallowing difficulties. 

Older individuals may have limited awareness of their inability to swallow as they may perceive this to be a normal part of ageing.¹³ As a result, they are not likely to seek any advice or treatment from healthcare professionals regarding medication swallowing difficulties.

Clinical implications

Pill aspiration occurs when the process of swallowing becomes uncoordinated, a tablet or capsule may accidentally penetrate the airways instead of efficiently travelling down the oesophagus.^14-16

As well as unsuccessful drug delivery, an aspirated tablet or capsule may also cause a series of further injuries to the airways,^17,18 which may lead to other health complications. 

Medication nonadherence that compromises therapeutic outcomes is of major concern in people with medication-swallowing difficulties.¹⁹ They often require extra effort or multiple attempts to successfully complete a swallowing task.⁸ Therefore, swallowing solid oral medications might become an unfavourable task for these people and they may decide to reduce the frequency or stop taking their medications entirely to avoid any stress or discomfort.²⁰

A study showed that pharmacists and physicians rarely inquired about a person’s ability to swallow medications.²¹ Similarly, only a few of the affected patients (13.7%) informed their physicians about these problems due to feeling embarrassed and the presumption that the physician would not be able to offer assistance.¹⁰ Since some individuals may not disclose their medication-swallowing difficulties, pharmacists should proactively approach affected individuals and offer help to facilitate medication swallowing.

Management

Amount of water

Water is the preferred choice of liquid for swallowing medications. It is recommended to swallow solid medications with at least 50–60 mL of water.^22-24

Some individuals may not swallow medication with any water, or use an inadequate amount, increasing the risk of medication getting stuck in the throat.³ This may cause drug-induced oesophagitis especially when taking certain medications such as doxycycline, NSAIDs, or bisphosphonates.²⁵

Postural adjustments

Postural adjustments aim at changing the head and neck positions to facilitate a safe swallow by altering the speed and flow direction of tablets and capsules, making them easier to swallow and reducing the risk of aspiration and laryngeal penetration.^26,27

There seems to be a common public misconception that tilting the head backwards (chin-up) is the best position to facilitate the swallowing of tablets and capsules. However, it increases the risk of aspiration by increasing the opening of the airway passage while narrowing the oesophagus.^28,29

Swallowing tablets with water and the head upright with no rotation may facilitate swallowing.³⁰ Other methods such as the “pop-bottle” technique involves placing a tablet on the tongue, sealing the lips tightly around a flexible water-filled bottle, and using a sucking motion to swallow both tablet and water.³¹

For capsules, the “lean-forward” position, where an individual brings the chin down towards the chest (chin-tuck)while swallowing the medication, may help direct the capsule down the throat with the help of water.³¹

Despite the usefulness of these postural adjustments, their safety profile varies between individuals with dysphagia and those who only have trouble swallowing solid medications without dysphagia.³² Consultation with the physician or speech pathologist is needed to determine suitability.³¹

Alternative dosage forms

Pharmacists can discuss alternative dosage forms to ease medication swallowing e.g. oral liquids, disintegrating tablets, wafers, patches, and injections. A discussion with the prescriber should be initiated by the pharmacist before any amendment to the prescription is made. If specific formulation is not commercially available pharmacists should consult a compounding pharmacy on the availability of other extemporaneous formulations before making a recommendation to prescriber.

Dosage form modification

Although most solid dosage forms are designed to be swallowed whole, some can be modified to ease swallowing if done appropriately. Common methods of dosage form modification include splitting, crushing or chewing tablets and opening capsules.³¹ These can be done by using spoons, syringes, knives, a mortar and pestle, and pill crushing devices.³² Potential drug losses while modifying dosage forms should be considered.³² Dosage form modifications are commonly practised by both those with and without medication-swallowing problems.^21,31 Some individuals modify dosage forms without consulting with their prescriber.³³

There are negative consequences associated with dosage form alteration which not all modfiers understand.^21,31 Inappropriate alteration of modified-release preparations and medication with a narrow therapeutic index may cause toxicity and undesirable adverse effects.³⁴ Certain modified-release preparations may be halved but cannot be crushed or chewed (see Table 1).

Mixing medications with food

Medicines are sometimes combined with food, crushed or uncrushed. Some medicines lose their effectiveness when prepared this way, and a pharmacist can advise on whether this method is appropriate.^36,37

Commonly used food vehicles include fruit puree, apple sauce, yoghurt, honey, custard and pudding to ease administration.^36,37 A speech pathologist and dietitian can advise on the most appropriate level of food textures and liquid consistencies to ensure a safe swallow.³⁸

When mixing medications with food, it is important to ensure complete consumption of the medication-containing food to avoid underdosing. Food-drug interactions when mixing medications with food and beverage should be considered.³⁹

Swallowing aids

Swallowing aids are available to make whole tablets and capsules easier to swallow without the need for modifying dosage forms. These aids aim to minimise any medication swallowing discomfort, as well as to improve medication adherence.³²

A medication lubricant is commercially available in Australia as a consumable oral gel and is recommended by the Australian Don’t Rush to Crush Handbook as one of the strategies to facilitate the swallowing of tablets and capsules for individuals who have trouble swallowing them.³⁵ This gel lubricates the tablets and capsules so that they can travel smoothly towards the back of the mouth and down the throat. It is also flavoured to mask any “taste” of the medications, which is often an obstacle described by patients with swallowing difficulties.³ A speech pathologist or physician should be consulted before using this product in patients with dysphagia. 

There are other aids that use different approaches to ease medication swallowing. These include pill-swallowing cups, pill-swallowing straws, mouth or throat lubricating sprays and pill-coating applicators.³² However, most of them are not currently approved medical devices by the Therapeutic Goods Administration in Australia.

Individuals with suspected dysphagia

Dysphagia can be a severe condition requiring immediate medical attention. Individuals with suspected dysphagia should be referred to see a speech pathologist for a comprehensive evaluation of swallowing function e.g. videofluoroscopy. Referral from a GP for a speech pathologist consultation is generally not required in Australia.⁴⁰ However, patients will need to visit a GP if assessment for Medicare rebates eligibility through the Chronic Disease Management program is required.⁴⁰

If the ability to swallow tablets or capsules is compromised as a result of dysphagia, patients may try the above strategies to ease solid medication swallowing only after consulting with or under the supervision of the physician and speech pathologist.

Table 1 – Modified-release preparations that can or cannot be halved, crushed or chewed.

Role of the pharmacist

Pharmacists should be able to differentiate between medication swallowing difficulties and dysphagia by recognising the contributing factors, and signs and symptoms associated with medication swallowing difficulties. 

Pharmacists can provide interventions to ensure medications are taken safely and effectively for individuals who only experience psychological swallowing difficulties. If dysphagia is suspected, pharmacists can refer the patient to a physician or speech pathologist for a comprehensive swallowing evaluation.

Since individuals may not voluntarily offer information about their problems with swallowing medications, pharmacists need to proactively approach them and discuss this issue. It is good practice to incorporate a discussion about medication swallowing difficulties when providing medication counselling to all patients. Pharmacists can recommend alternative dosage forms that are easier to swallow after discussing patient preference. Pharmacists can be involved in simplifying complex dosage regimens and recommending combination products or once-daily doses to minimise intake and improve adherence. 

Should dosage form modification be deemed plausible, pharmacists may opt to do this. There are legal implications associated with such modification as it may be considered “off-label” use, meaning the liability will fall on the person who instructs or performs the modification.⁴⁴ The Australian Don’t Rush to Crush Handbook provides evidence-based information on the appropriateness of dosage form modification. This resource can also be accessed through AusDI and MIMS online. 

Pharmacists can recommend the use of medication lubricating gel in patients who only have medication-swallowing difficulties without dysphagia to help ease medication swallowing and to mask the taste of medications.

Conclusion

Some individuals may not necessarily have dysphagia but simply a psychological aversion to swallowing tablets and capsules. Individuals may opt to modify dosage forms to ease swallowing, however inappropriate modifications may be harmful which may result in serious health and legal consequences. Some individuals may not necessarily be willing to offer information about their struggle with swallowing tablets and capsules. Therefore, pharmacists should proactively initiate the conversation with their patients and help them find management solutions. For individuals at high risk of developing dysphagia or further complications, appropriate referral to their GP or a speech pathologist will be required.

Acknowledgement

The information in this article is derived from the authors’ Ph.D. theses. Both authors would like to acknowledge Prof Lisa Nissen, A/Prof Kathryn Steadman, Dr Esther Lau, Dr Julie Cichero, and Dr Manuel Serrano Santos for their contribution and support.

Key points

• There are differences between medication-swallowing difficulties and dysphagia.
• Some individuals may only have trouble swallowing tablets and capsules and have no trouble swallowing foods or liquids.
• Pharmacists need to be proactive in initiating the conversation about medication-swallowing difficulties.
• Management strategies for medication-swallowing difficulties include providing appropriate advice on dosage form modification, postural adjustment, mixing medication with foods, and recommending appropriate swallowing aids.

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DR SIMON YEW MUN WONG PhD, BPharm(Hons), FHEA, AFHEA (Indigenous) is an Associate Lecturer in Pharmacy at the Queensland University of Technology.

DR AIDA SEFIDANI FOROUGH PhD, PharmD, AFHEA, AFHEA (Indigenous) is a Lecturer in Pharmacy in the School of Clinical Sciences at the Queensland University of Technology.