JCPSLP Vol 17 No 2 2015_web

Clinical insights

A multidisciplinary approach to difficulty swallowing medication An alternative to dose form modification Emily Davis and Derek Kay

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. D ifficulties 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

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

KEYWORDS DOSE FORM DYSPHAGIA MEDICATION PHARMACY TABLET

Emily Davis (top) and Derek Kay

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JCPSLP Volume 17, Number 2 2015

www.speechpathologyaustralia.org.au