Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations

Abstract

Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team—including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers—is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.

Point Prevalence Survey of Acute Hospital Patients with Difficulty Swallowing Solid Oral Dose Forms

“…Patients were identified as having a swallowing difficulty if (i) there was advice on fluid, food, or medicine consistency available or (ii) there was an enteral feeding tube in situ, (iii) the nurse considered that the patient had a swallowing difficulty, or (iv) the patient chewed SODFs. The prevalence was much higher than that identified in our study because patients in older adult care wards and stroke wards are more likely to have swallowing difficulties [26], so the two cohorts are not directly comparable.…”

“…Yoghurt was the most popular food stuff used to administer modified SODFs. The use of yoghurt as a vehicle has also been previously reported [11,26,28]. The appropriateness of yoghurt as a vehicle has not been studied, as far as the authors are aware.…”

“…Our study found a much lower prevalence of swallowing difficulties in hospital inpatients without an enteral feeding tube (9.6%) than this. However, the populations differ in that only those greater than 65 years were included, and some patients were in long-term care, where it would be expected that a higher prevalence of swallowing difficulties would be found [26]. Furthermore, it is unclear from the study how patients with swallowing difficulties were identified for inclusion.…”

“…Additionally, it has been reported that significant and sustainable quality improvement in medication administration in nursing home residents with swallowing difficulties can be achieved following the implementation of a programme that includes education, the introduction of a protocol and pocket cards, the screening of medicines by pharmacy technicians, and the annotation of charts with advice on crushing [33]. Additionally, some medicines, including those with antimuscarinic activity and calcium channel blockers, are considered to potentially induce dysphagia, something that also needs to be recognized at patient reviews [26].…”