Swallowing Issues and Dysphagia

Swallowing Issues and Dysphagia

I find it hard to resist a good leaflet. At Continuing Professional Development (CPD) events there’s often a wide choice and it would be rude not to take at least one. At the time I’m full of good intentions to read them, but all too often the leaflets are placed on a ‘read later’ pile, which over several months/years becomes precariously tall.

The other day I tackled ‘the mountain’ and came across several leaflets on swallowing difficulties from Rosemont Pharmaceuticals Ltd. ®. I started reading and was soon reminded of how common it is for people to have problems taking their medication. In my own practice I’ve noticed increased prescribing of orodispersible tablets and, when dispensing for care homes, a lot of crushing of tablets is required.

We’ve probably all struggled at some time or another to take tablets or capsules. A 2007 article published in “Pharmacy In Practice” suggested around 60% of people over the age of 60 sometimes struggle to swallow solid medications. As part of the survey, people were asked if they have ever needed to open a capsule or crush a tablet in order to swallow the medication and 70% of respondents said they had. A similar proportion admitted to not taking their medication, as it proved too hard to swallow.

If a patient reports difficulty taking their medication, there are usually alternative dosage forms that can help to alleviate the problem. However, perhaps less than a third of patients are asked by their prescriber if they have difficulties taking tablets or capsules before they are given a prescription. This is when non-compliance could be an issue, not because patients don’t want to take their medication, but because they can’t physically take it.

Dysphagia is a common problem and there are several causes:

• Neurological causes (damage to the nervous system can interfere with the nerves responsible for starting and controlling swallowing) – stroke, Parkinson’s disease, multiple sclerosis, dementia, motor neurone disease, etc.
• Congenital and developmental conditions – learning disabilities, cerebral palsy, cleft lip and palate
• Obstruction – some conditions cause an obstruction in the throat or a narrowing of the oesophagus, which can make swallowing difficult – mouth cancer, GORD, infections (e.g. TB and thrush can lead to oesophageal inflammation), etc.
• Muscular conditions (rare) – scleroderma and achalasia (I had to look these up too!)
• Ageing – as you get older, the muscles used for swallowing can become weaker and this may explain why dysphagia is relatively common in elderly people
• COPD – makes it difficult to breathe in and out easily and this can impact on the ability to swallow properly

Pharmacists have a key role in supporting patients to take their medicines and recommending alternatives if they become aware a patient can’t take their medication easily. For more information http://swallowingdifficulties.com has some excellent resources for patients and healthcare professionals. I particularly like the facility whereby you can type in the name of a drug and get an instant report of the forms in which it is available. Also, particularly useful for healthcare professionals, there is additional information on coatings and an indication of whether it would be safe or appropriate to crush.

As professionals it is vital to remember that crushing a tablet or opening a capsule means you are changing the form of the medicine, meaning that the use of the drug in this way is unlicensed.

Licensed medicines have been tested for effectiveness and safety and there will be an associated data sheet giving all the licensed indications, routes of administration, etc. There are legal consequences of crushing tablets. When something is prescribed off-license the liability rests with the prescriber and crushing or dispersing a tablet would render it unlicensed, unless this is recommended in the data sheet (probably unlikely in most cases). Other healthcare professionals without prescribing rights are not legally permitted to recommend medicines for off-label unlicensed use – doing this would contravene the Medicines Act.

It’s very important to consider medicines optimisation in patients with dysphagia. Keele University has done a great deal of work in this area and supports the following website https://www.dysphagia-medicine.com/index.html.

Finally, it’s not just adults who have problems taking their medicines, so go to the Medicines for Children website to find out more about helping children swallow tablets. If we start helping children, then we may not have as many adults who say they can’t take tablets in the future!