Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia

Abstract

We evaluated the prevalence of difficulties swallowing solid dosage forms in patients with stroke-induced dysphagia and whether swallowing tablets/capsules increases their risk of penetration and aspiration. Concurrently, we explored whether routinely performed assessment tests help identify patients at risk. Using video endoscopy, we evaluated how 52 patients swallowed four different placebos (round, oval, and oblong tablets and a capsule) with texture-modified water (TMW, pudding consistency) and milk and rated their swallowing performance according to the Penetration Aspiration Scale (PAS). Additionally, Daniels Test, Bogenhausener Dysphagiescore, Scandinavian Stroke Scale, Barthel Index, and Tinetti's Mobility Test were conducted. A substantial proportion of the patients experienced severe difficulties swallowing solid oral dosage forms (TMW: 40.4 %, milk: 43.5 %). Compared to the administration of TMW/milk alone, the placebos increased the PAS values in the majority of the patients (TMW: median PAS from 1.5 to 2.0; milk: median PAS from 1.5 to 2.5, each p value <0.0001) and residue values were significantly higher (p < 0.05). Whereas video-endoscopic examination reliably identified patients with difficulties swallowing medication, neither patients' self-evaluation nor one of the routinely performed bedside tests did. Therefore, before video-endoscopic evaluation, many drugs were modified unnecessarily and 20.8 % of these were crushed inadequately, although switching to another dosage form or drug would have been possible. Hence, safety and effectiveness of swallowing tablets and capsules should be evaluated routinely in video-endoscopic examinations, tablets/capsules should rather be provided with TMW than with milk, and the appropriateness of "non per os except medication" orders for dysphagic stroke patients should be questioned.

Brain imaging correlates of recovered swallowing after dysphagic stroke: A fMRI and DWI study

“…Patients post-stroke, who were severely dysphagic during the rehabilitation period (within the last 3 years prior to the study), were invited to a follow-up swallowing function assessment. Severe dysphagia during the subacute phase after stroke was operationalised using the Bogenhausen Dysphagia Score sum of scores (BODS1 and BODS2; Schiele et al, 2015, Starrost et al, 2012). These scores are used by therapists and physicians in the German speaking areas of Europe and show impairments of saliva swallow and food intake in clinical/neurological testing.…”

“…This test has a sensitivity of 92.7% and a specificity of 66.7%. Further, an assessment concerning the impairment of saliva swallow and food intake was performed based on the Bogenhausen Dysphagia Score [BODS, consisting of BODS1 and BODS2 (Schiele et al, 2015, Starrost et al, 2012) with a maximum sum of scores of 16]. A score between 0 and 2 means no dysphagia and between 14 and 16 means profound dysphagia.…”

Conhecimento das equipes médicas e de enfermagem sobre o manejo de medicamentos orais no paciente adulto disfágico hospitalizado

“…Thus, thinking about medication modification is the most logical option when the patient has difficulty swallowing. Even though this is the practice found in this study, other studies (17,21,22) have shown that modifying tablets (breaking, smashing, crushing or dissolving) and capsules (opening), in addition to resulting in unlicensed use, can be toxic to the patient and decrease the action potential, since some drugs are designed to be absorbed in specific places in the digestive tract.…”

Swallowing Disorders in Patients with Stroke

“…This is a useful method which enables observation of the pharynx and larynx using actual food without irradiation. This can be used at the bedside as it does not require any large-scale devices [29].…”