Recently, I performed a swallow evaluation on a patient who had sustained a brainstem stroke. It was a Sunday morning, and he had been admitted to our hospital sometime the night before. The patient was moderately dysarthric but able to communicate effectively via a combination of speech, gesture, and writing. He expressed that he was having trouble swallowing and couldn’t “move the food back” with his tongue.
An examination of his oral mechanism revealed significantly slowed lip and tongue movements with limited tongue elevation and lateralization. When provided a sip of water, he held the water in his mouth for a prolonged period and appeared to struggle to initiate a swallow. Eventually, he swallowed the water, coughed briefly, and requested another sip.
Instead of more water, I provided ice chips which he struggled to move in his mouth but was eventually able to swallow without coughing. He was able to swallow some puree, expelling a bit from his mouth without swallowing, after which he wrote, “I can’t get it all back.” Clearly, a significant dysphagia was present.
An instrumental swallowing assessment had been ordered but was unlikely to be completed until early the following morning. In the meantime, the patient’s nurse had several important medications to administer, including his blood pressure medication. His blood pressure was dangerously high, and she was concerned about the delay in administration that had already occurred. “Can he swallow this?” she asked, holding up the tablet in its blister pack
Two questions came into my mind: What is the risk if this patient swallows his medication? And what is the risk if this patient does not swallow his medication?
Understanding Oral Medication Challenges
Pill swallowing is difficult for many people and can be especially problematic for people with dysphagia. Unlike swallowing food and liquid, pill swallowing is something we must consciously learn to do, and many people, both with and without dysphagia, report difficulty doing so.
To swallow pills effectively, we must swallow them whole, which means overriding our natural impulse to chew, an automatic response to solid boluses of that size. We must also avoid the gag response, a function that keeps us from swallowing food items that are too big to be swallowed.
Add to that the bitter taste of some medications on the tongue, the challenge of managing solid and liquid boluses simultaneously, and the anxiety that some have around medications, and it is clear that pill swallowing presents unique challenges.1
A patient with swallow impairment at baseline is even more likely to have difficulty, putting our patients with dysphagia at particularly high risk. Pill swallowing also varies with the shape and size of the medication. Most of us find that coated tablets are easier to swallow than non-coated, smaller pills are easier to swallow than larger ones, and torpedo-shaped pills or capsules are easier to swallow than round tablets.2 Many people alter the medication in some way—crushing pills, opening capsules, or cutting or splitting tablets—to make them easier to swallow. Unfortunately, doing so may impact the medication’s effectiveness, peak effectiveness, and/or the site of absorption in a negative way.
Evaluating the Risks Associated with Oral Medication
In the example above, the patient’s swallow impairment could cause a pill to become lodged in his airway. If not cleared from the pharynx or the airway, the medication could damage the mucosa. If all or part of the medication is aspirated, a serious lung infection could result. This medication could be safely crushed per the pharmacy guidelines however, in this case, that may or may not reduce his aspiration risk.
Now that we’ve evaluated the risk to the patient if he attempts to swallow the medication, let’s look at the risk if he does not swallow the medication. This patient had a stroke very recently. Currently, his blood pressure is dangerously high, and he needs this medication to bring it into better control. Given his recent hospital admission and new dysphagia, he has already missed one dose of this medication today.
Given that there are two sets of risks, we must decide which risk is greater—the risk of extending his stroke and further neurological damage or the risk of aspiration and lung infection?
Deciding How to Proceed
After explaining the situation to the patient, he expressed that he wanted to try to take the medication. The nurse crushed the medication, mixed it with applesauce, and administered it slowly in small amounts. We provided ice chips intermittently to help to clear the oral cavity and to access the cold temperature to assist with swallow response stimulation. It was a painstakingly slow process, but together we managed to administer the medication as safely as possible.
Was that the right decision to make? I remain unsure of that, but I do believe that together, the patient, nurse, and I made the best decision we could with the resources we had in the moment. While we did not yet have the information from an instrumental swallowing assessment to guide us, we were able to utilize the results of the clinical assessment to identify potential compensatory strategies.
The nurse had access to our pharmacy’s guidelines and, in conjuction with the pharmacist and physician, she was able to prioritize which medications were critical to administer. We were also able to utilize our electronic medical record to alert the physician, pharmacist, as well as the nurses and SLPs on upcoming shifts, to the patient’s difficulties. The patient, while dysarthric, was able to communicate effectively via writing and was able to participate in the decision-making and problem-solving process.
Patients with dysphagia are unfortunately much more likely to have trouble swallowing medication and are also more likely to be subject to medication errors, particularly in the use of altered dosage forms like crushing medications as we chose to do in this patient’s case.3 Perhaps there is no “right” choice. Rather, patients, SLP’s, nurses, physicians, and pharmacists can and must work together to assess each unique situation and make medication administration as safe and efficient as possible.
- Radhakrishnan, C., Sefidani Forough, A., Cichero, J. A. Y., Smyth, H. E., Raidhan, A., Nissen, L. M., & Steadman, K. J. (2021). A difficult pill to swallow: An investigation of the factors associated with medication swallowing difficulties. Patient Preference and Adherence, Volume 15, 29–40. https://doi.org/10.2147/ppa.s277238
- Overgaard, A. B., Højsted, J., Hansen, R., Møller-Sonnergaard, J., & Christrup, L. L. (2001). Patients' evaluation of shape, size and colour of solid dosage forms. Pharmacy world & science : PWS, 23(5), 185–188. https://doi.org/10.1023/a:1012050931018
- Sefidani Forough, A., Lau, E., Steadman, K. J., Kyle, G. J., Cichero, J., Serrano Santos, J. M., & Nissen, L. M. (2020). Appropriateness of oral dosage form modification for aged care residents: a video-recorded observational study. International journal of clinical pharmacy, 42(3), 938–947. https://doi.org/10.1007/s11096-020-01036-x