JCPSLP Vol 17 No 2 2015_web

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JCPSLP Volume 17, Number 2 2015 91
Clinical insights
KEYWORDS
DOSE FORM
DYSPHAGIA
MEDICATION
PHARMACY
TABLET
Emily Davis (top)
and Derek Kay
difficulty swallowing. Of the patients who reported that
they had difficulties swallowing their tablets, 58.7% had
modified their medication in a way that may have altered
the effectiveness and safety of the medication. Notably,
participants reported that the shape of the tablets they were
prescribed affected how easy they were to swallow.
Assessing and addressing
swallowing difficulties
In a hospital environment, a multidisciplinary team approach
to ensure patients can swallow their medication is
important. Typically, the speech-language pathologist (SLP)
assesses the patient’s swallowing ability and the pharmacist
provides information on alternative or modified dose forms
and compatibility with taking with thickened fluids. Nurses
supervise the administration of medications and identify if
patients are having difficulty swallowing and the medical
team is responsible for writing or amending medication
charts. This multidisciplinary team approach aims to
facilitate compliance and reduce adverse drug events.
Some key considerations and common strategies for
addressing difficulties swallowing medications are
presented below.
Modification of dose form may improve a person’s ability
to swallow medications safely. Dose form modifications and
alternatives include:
• cutting tablets in half
• crushing tablets
• opening capsules
• giving whole or crushed medications with thick fluids
• dispersing/dissolving the medication in liquid
• giving liquid formulations
• thickening liquid formulations.
A pharmacist should be consulted to ensure that
these modifications are not contraindicated, and to
ensure the patient receives the least modified option. To
illustrate, the modification of tablet dose forms may result
in an “off licence” use if crushed. Some medications
need to be swallowed whole with a glass of water to
reduce oesophageal irritation (including alendronate and
tetracycline antibiotics). People with dysphagia may be
unable to do this. Other medications that must be taken on
an empty stomach cannot be taken with thick fluids.
With regard to crushing, even when it is possible, this
may result in an unpalatable taste, cause irritation, or
result in an inconsistent dose being administered (Nunn
& Williams, 2005). Cutting tablets, on the other hand, can
result in sharp edges, and patients sometimes complain
Difficulties swallowing tablets is an
underrecognised and important issue that
negatively impacts the health and well-being
of many adult clients, and is not limited to
individuals with dysphagia. Clients who
experience difficulties may miss doses or
resort to modifying medications in potentially
dangerous ways to improve their ability to
swallow them, such as crushing medications
that should not be crushed. The cost of
alternative liquid medications, where
available, may be prohibitive. The purpose of
this “Clinical insight” is to present a case in
which assessing and addressing the
swallowing difficulties of a single patient led
to a service-wide switch to an alternative
brand of medication that was easier to
swallow. Changing the brand of tablets
resulted in a “least modified” approach for
this patient and an easier tablet to swallow
for other patients. The case highlights that
multidisciplinary care, including in this case
input from a speech-language pathologist, is
essential in optimising medication dosing.
Difficulties swallowing tablets is common in older
people and people with dysphagia, but not limited
to these populations (Schiele, Quinzler, Klimm,
Pruszydlo, & Haefeli, 2013). Anyone may have difficulties
swallowing medications, or find certain medications harder
to swallow than others. People who experience difficulties
may miss doses or attempt to alter the dose form (e.g.,
crush tablets) which may reduce medication effectiveness
and result in harm (Marquis et al., 2013). Given the risks,
speech pathologists have an important role to play as part
of a multidisciplinary team in identifying and addressing
these swallowing difficulties.
There is evidence to suggest that difficulties with
swallowing medications may be underrecognised in health
care settings. Schiele et al. (2013), for example, reported
that 1 in 11 patients who attended their general medical
practice had difficulties swallowing tablets or capsules, but
70.4% of the patients who reported difficulty swallowing
tablets were not identified by their GP as having any
A multidisciplinary
approach to difficulty
swallowing medication
An alternative to dose form modification
Emily Davis and Derek Kay