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How to tackle medication-related dysphagia

Heather Morris
RGN RM
Specialist Nurse
HM Auditing Ltd

Mark Greener
Pharmacologist and Pharmaceutical Industry Consultant

Swallowing problems (dysphagia) become increasingly common with advancing age, and potentially complicate the nursing care of older patients. This article reviews some of the ways in which nurses can address the problem when it is caused by the patient's medication


Dysphagia can cause numerous unpleasant symptoms (see Table 1), undermine nutrition, result in aspiration pneumonia, compromise quality of life and hinder administration of solid medications.1 Up to a third of nursing home residents experience difficulties swallowing, while a recent study (see below) suggests that medication-related dysphagia is even more common in older people living in the community.2,3

[[Table 1 dysph]]
 
A common practice is for nurses to crush tablets or open capsules.2,3 However, this can leave patients vulnerable to poor therapeutic outcomes and nurses vulnerable to medicolegal action. On the other hand, as Penner et al remark: "Nurses are in a key position to provide support and initiate appropriate interventions for individuals with dysphagia".4 This article will consider some interventions that nurses can initiate to address medication-related dysphagia.

A common problem
Nurses will often encounter patients exhibiting the characteristic signs and symptoms of dysphagia (see Table 1). In one study, 44% of retired people suffered swallowing problems severe enough to interfere with their daily life.5 Other estimates suggest that between 35–68% of elderly people experience some degree of dysphagia.6  Nurses should look out for the hallmark symptoms and signs, rather than relying on patient reports alone. Some patients, even those with severe dysphagia, may be reluctant to admit to having difficulties swallowing.

Combinations of several factors result in dysphagia posing a particular problem among older people. First, the motility of the gastrointestinal tract alters as part of physiological senescence. One study enrolled elderly patients who did not experience dysphagia or eating difficulties, of which only 16% showed normal swallowing.7 However, the clinical significance of such age-related physiological changes remains unclear.8 

Second, several diseases, including type 2 diabetes,8 carcinoma, stroke and advanced Alzheimer's disease – which become more common with advancing age – influence the likelihood of developing dysphagia.1 For example, up to half of patients with chronic diabetes mellitus may show reduced gastric emptying.8 Oesophageal motility declines as diabetes mellitus duration increases.9 Stroke increases the risk of dysphagia by 64–69%. The risk of dysphagia is particularly high among stroke survivors with hemiplegia and aphasia.10

Third, medication side-effects can contribute to dysphagia. Older patients may receive drugs that influence gastrointestinal motility, such as certain antidepressants and other agents with anticholinergic actions, opioids and calcium antagonists.8 A study of 600 older Americans found that 33% took at least one medication that could induce xerostomia (dry mouth due to lack of saliva).11 Treatments more likely to induce xerostomia include tricyclic antidepressants, certain beta-blockers, and several diuretics.12 The number of items prescribed to older people almost doubled between 1997 and 2007, from an average of 22.3 to 42.4 items per head.13 Therefore, the risk of medication-related dysphagia and the likelihood of receiving a drug linked to xerostomia increased markedly in recent years.

As a result of these and other factors, difficulties swallowing solid dosage forms (capsules and tablets) are common among older people living in the community. In 2005, it was reported that almost 60% of patients presenting to community pharmacists experienced problems swallowing tablets or capsules. Furthermore, 68% admitted opening a capsule or crushing a tablet to swallow their medication, while 69% reported nonadherence because medications were hard to swallow (see Table 2).14 A more recent survey of older people presenting to community pharmacists shows broadly similar results (see Table 3). Overall, around half of people older than 65 years of age in the general community experience difficulties swallowing tablets or capsules.

[[Table 2 dysph]]

[[Table 3 dysph]]

"To crush or not to crush"
Against this background, it is perhaps not surprising that nurses often crush tablets or open capsules, or suggest that patients and carers manipulate the formulations to aid administration. In a recent survey of community pharmacies, 35% of patients or carers reported that their healthcare professional advised them to open the capsule or crush the tablet to make the formulation easier to swallow. Furthermore, a study of medication administration by nine nurses in two elderly long-stay psychiatric wards found that crushing tablets without authorisation was the most common medication administration error, accounting for 28.7% of mistakes. Nurses crushed the tablet without authorisation when administering 7.4% of doses. Opening a capsule without authorisation accounted for 1.4% of errors and occurred in 0.4% of doses.15 

In another paper, the same group reported that nurses crushed tablets or opened capsules to administer 25.5% of solid oral doses. The prescriber had authorised tablet crushing in only 56% of these cases. In almost one in 20 (4.5%) cases, crushing was specifically contraindicated.16 Clearly, nurses who experience problems administering a treatment to a patient should discuss the management regimen with the prescriber and consider alternative formulations and routes of administration. In this case, the authors estimate that using alternative formulations would avoid 57.5% of tablet crushing.16

While nurses open capsules and crush tablets with the best of intentions, such manipulations can have several adverse consequences. For example, manipulating certain formulations can influence pharmacokinetics (the pattern of absorption, distribution, metabolism and excretion). Crushing a tablet that is enteric coated to deliver the medicine in the small or large intestine may result in the drug not reaching the intended site. Crushing a modified release tablet or opening the capsule may damage the slow release mechanism. As a result, the patient receives the full dose more rapidly than the manufacturer intended, while receiving little or no dose during the rest of the dosage interval.17

Importantly, the European Medicines Agency (EMEA) approves drugs on the assumption that the dosage formulation is not modified before administration, one factor that may shift the medicolegal onus onto nurses who suggest opening a capsule or crushing a tablet (or advising a patient or carer to). Recent guidelines warn that healthcare professionals who advise that a tablet is crushed or a capsule opened to assist with swallowing difficulties could be legally liable (due to negligence) for any resulting harm.17

The recent consensus management guidelines note that the clinical outcome of such manipulations may be more marked in the elderly, reflecting age-related alterations in pharmacokinetics. Furthermore, the risk that these manipulations will undermine efficacy and increase the risk of side-effects is especially marked in drugs with narrow therapeutic indices such as phenytoin, digoxin, carbamazepine, theophylline and sodium valproate. According to our survey, two-thirds of patients and carers thought that opening a capsule or breaking a tablet would not influence tolerability or efficacy. Therefore, nurses should remind patients that manipulating formulations potentially undermines outcomes.17

Nurses should be aware of the potential risks to their own health when crushing or opening some formulations. For example, crushing tablets containing hormones, cytotoxins or steroids may disperse the agent in the air. This could expose the administrating nurse or carer to a potentially toxic agent.17

Alarm symptoms
Dysphagia is an alarm symptom for certain cancers (eg, mouth, throat or oesophagus) and other gastrointestinal disorders. Therefore, enquiring about swallowing difficulties should be a standard part of the assessment of older people. The prevalence of such problems increases with advancing age. For example, people aged over 55 years are 9.5 times more likely to develop gastrointestinal cancer than younger people.17

Nevertheless, a third of patients and carers reported that their healthcare professional never asked if the patient experienced difficulties swallowing before issuing a prescription. While prone to recollection bias, the relatively high proportion suggests that nurses and other healthcare professionals do not make such an enquiry regularly. 

Finally, nurses should remember that medication-related dysphagia contributes to noncompliance; almost three in every five patients did not take a tablet or capsule in the last year because of difficulties swallowing. In other words, a quarter of all elderly patients do not comply because of medication-related dysphagia.

The recent survey suggested that healthcare professionals may be largely unaware of the scale of the problem: 42% of patients said that they do not inform a healthcare professional if they do not adhere because of dysphagia. Addressing swallowing difficulties should improve adherence. However, there is no "magic approach" that improves compliance and nurses need to instigate a multifaceted approach.

Managing medication-related dysphagia
The guidelines recommend that nurses and other healthcare professionals should always ask if the patient experiences difficulties swallowing solid medication; attempt to ascertain the reasons and tailor the formulation appropriately (see Figure 1).12 When patients experience difficulties swallowing a solid oral drug, nurses and other healthcare professionals should check with a pharmacist, a Medicines Information Centre, or both, to ascertain whether alternative formulations – such as transdermal, parental, buccal, rectal or liquids – might be appropriate for some patients who experience difficulties swallowing.17

[[Figure 1 dysph]]

Nurses can aid the implementation of this algorithm. A focus group of 10 healthcare professionals, including nurses, involved in the care of people with swallowing difficulties identified three main themes that hinder effective management:

  • The spectrum of dysphagia (as a symptom of numerous diseases).
  • Formulation issues.
  • Problems with the correct information being with the right person at the right time, in the right place.6 

As the guidelines note, simply asking whether a patient experiences swallowing difficulties (or the symptoms in Table 1) should identify patients with medication-related dysphagia irrespective of cause. The growing number of liquid and alternative formulations should help tailor treatment to each patient. Liquid formulations can be more expensive than traditional solid forms. However, prescribers need to set these costs in context.

For example, adherence with oral drugs for type 2 diabetes is lower than that seen during the treatment of many other conditions: between 40–75% of older patients do not adhere to their prescribed medication for diabetes.18 Even a 10% improvement in compliance potentially reduces the risk of microvascular complications by 3.7%. It was recently estimated that increasing compliance by 10% could save the NHS up to £1.5bn, excluding the additional costs of new treatments.19

Addressing the final theme identified by the focus group – ensuring the correct information is with the right person at the right time, in the right place – may require "system" changes. One study found that process changes, such as including recommendations made by a speech-language pathologist on the medication administration record and a "dysphagia alert" on the pharmacy computer system helped prevent inadvertent prescribing, dispensing or crushing of sustained-release medications in patients with dysphagia.20 

Against this background, Werner suggests that dysphagia clinical nurse specialists can "facilitate a consistent approach" to the management of this common and often complex problem.21 The clinical specialist liaises with the interdisciplinary team and nursing staff to oversee the nursing care of people with dysphagia. In the community or nursing home, a formal clinical nurse specialist role might not be justified. However, an interested nurse could consider taking a local lead, liaising with other medical colleagues, physio- and other therapists, and community pharmacists.

Conclusions
Medication-related dysphagia is common, affecting around half of older people in the community. A quarter open a capsule or crush a tablet to aid administration and swallowing difficulties undermine adherence in a similar proportion. Therefore, nurses should enquire about, and remain vigilant for, dysphagia generally and problems swallowing medications in particular.

Nurses should consider liquid and other alternative formulations for patients experiencing medication-related dysphagia and take a lead in the appropriate management of this increasingly common condition.

References
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13. Prescriptions dispensed in the Community 1997–2007. Available from: www.ic.nhs.uk/pubs/presdisp97-07
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References
16. Stubbs J, Haw C, Dickens G. Dose form modification – a common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients.
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19. Greener M. Diabetes: Improving Compliance. Geriatric Medicine 2008:46-52.
20. Jackson LD, Little J, Kung E et al. Safe medication swallowing in dysphagia: a collaborative improvement project. Healthc Q 2008;11(3):110-6.
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