Swallowing problems

Swallowing problems can be the result of a neurological or physical impairment, or can occur relating to dry mouth (which may be medication-related) or fear of choking.⁹⁰³

Helping patients with swallowing problems to take medication

1, Review all medication⁹⁰⁰
How essential is the medication? Is the patient gaining a worthwhile benefit from it?

2, Is the patient’s technique in taking tablets good? Would they benefit from training?⁹¹²

3, Review formulations⁹⁰⁰
Can the medication be given by a-non oral route? E.g. transdermal, rectal, topical application.

4, Review choice of medication⁹⁰⁰
Is there another medication which has a more appropriate formulation or is available by a non-oral route? E.g. fentanyl patches instead of oral opiates; ramipril oral solution instead of perindopril tablets.

5, Reduce the number of oral doses⁸⁹⁹
Choose medications with a long therapeutic effect (e.g. medications which can be given only once daily) to reduce the frequency of medicines administration.

6, Choose the most appropriate formulation for the patient’s needs
This may not always be a liquid medicine, particularly if the patient requires thickened fluids. Think about tablet size and shape.

7, Provide information and training to the patient and/or carer on how to prepare and administer the medication.⁹¹²

Licensed and unlicensed medications

Medications which are being taken in a different way from the manufacturer’s instructions (e.g. when tablets are crushed or capsules are opened and this is not a method described in the product license) are being used “off-label”, which means that the manufacturer does not accept responsibility for any harm caused by the administration.⁹⁰⁰ Prescribers must be aware when medications are being used off-label, and the decision to do so must be recorded in the patient’s care records.

Generally it is preferred to use a licensed medication in an unlicensed (off-label) way, such as by crushing tablets or opening capsules, than to use an unlicensed medication, which does not go through the same degree of rigorous testing during manufacture as a licensed product.⁹⁰³ The MHRA acknowledges that the use of licensed medications “off-label” is preferred to the use of unlicensed medications.⁹⁰³

Considerations when administering medications to patients with swallowing problems

1, Who will be administering the medication?⁹⁰³
It is important to consider who will be preparing and giving the medication. Are they able to follow the instructions? Do they have the manual dexterity to do so?

2, Swallow assessment⁹⁰⁴
Following a swallow assessment, the speech and language therapist will advise on what types of food the patient can safely eat, and whether they can swallow whole tablets or capsules. Moving to liquids is not necessarily appropriate. Small tablets may often be safely swallowed with foods of a suitable consistency.

3, Health and safety issues^900,903
Carers handling medications, particularly if they are crushing tablets or opening capsules, may be at risk of inhalation or topical exposure to the medication. This is particularly important in the case of cytotoxic medications, antibiotics, immunosuppressants and hormones, or when the carer is a woman of child-bearing age. A “closed” method of preparation of such medications, such as a crushing syringe, may be advisable.

Administering medications

Changing the way in which a medication is presented, such as by crushing a tablet or opening a capsule when this is not recommended by the manufacturer, can alter the medicine’s absorption characteristics, prevent it from reaching its site of action, cause local irritation, make the medication unstable and / or result in a preparation with an unacceptable taste or an anaesthetic effect in the mouth.⁹⁰⁰ Therefore this should generally only be done when no other method is suitable for the patient.

Not all tablets are suitable for crushing / dispersing, and not all capsules are suitable for opening. The drug monographs in this guide provide information on many medications – other medications which are not discussed here should be reviewed by a pharmacist before a decision is taken to manipulate a medication in this way.

- Patients able to swallow thin liquids can use oral liquid medicines, dispersible and effervescent tablets, as well as medications dispersed in water.⁹⁰³

- Patients who require thickened fluids may be able (on the advice of the speech and language therapist) to swallow whole, halved, or crushed tablets administered with appropriately thickened fluids.⁹⁰³

- Those who are able to manage a soft food diet may be able (on the advice of the speech and language therapist) to swallow whole, halved, or crushed tablets with food of the appropriate consistency.⁹⁰³

It is generally believed to be more palatable to patients to take medications with food, rather than as crushed tablets in water or thickened fluids.⁹⁰⁴ Before giving a medication in food it is important to check that it is not intended to be given on an empty stomach (contact Pharmacy for advice, or look at the pharmacy label on the packaging as this often states whether the medicine should be taken on an empty stomach). When medications are added to food, they should be added to the first mouthful of food to ensure that the whole dose is taken.⁹⁰⁴

When medications are manipulated to aid administration, or given in food, it is important that they are given in a consistent way with each dose, in order to reduce fluctuations in effect and side effects.⁹⁰⁴

Some medications interact with calcium – these medicines are labelled with the instruction to avoid dairy products. If mixing these medications with food, non-dairy foodstuffs should be used, e.g. jam.