Pill Swallowing: You’re not the only one who has trouble

Do you like swallowing pills? Probably not. Nobody enjoys it. But for a growing number of us, swallowing pills can be difficult, stressful, and can pose a serious issue towards effective medication management. In one recent study, out of a group of 152 healthy individuals, about a third might be expected to have difficulty swallowing medication. This means, that pill dysphagia is much more prevalent than even the general diagnosis of dysphagia itself which is only about 4.5% of the general population. There’s a reason why “it’s a hard pill to swallow” became an expression instead of “it’s a hard bolus to swallow” (I’m aware no non-SLP would ever come up with that expression, but you get the point).

For better or worse we look to medication to solve most of our ailments. The majority of us and almost 90% of patients over 65 are on some level of medication. Pill dysphagia may potentially cause huge issues, especially when it becomes a barrier to the essential management of harmful conditions. This issue can be exacerbated as physicians may be unaware of their patients’ pill dysphagia while they continue to prescribe large amounts of large pills.

Dysphagia

It shouldn’t be a surprise that those with dysphagia (aka our patients), will have more difficulty with medication than the general population. Carnaby-Mann, et al. in 2015 found that 61% of patients with dysphagia had difficulty swallowing meds with signs that included coughing, expectoration of medication, and struggling to swallow. Further, there was residue observed on more than half of the trials and aspiration on 14% of trials. Yikes. Makes you think twice about recommending NPO except for medication, doesn’t it?

The question then is: Is there a way to do this better?

Just a little crush

If a pill is too large (and not in capsule form), one way to conquer that horse pill is to smash that sucker into pieces. Simply break it down into dust and then take it with some water or apple sauce, right? Well, here’s the thing- Crushing certain medications may result in a number of negative outcomes. One is that it alters their release time. This means that medication could enter the bloodstream way too quickly, providing a blast of chemicals instead of a steady flow. This rush of chemicals can result in toxicity and even death (though a rare occurrence). It may also mean that you are mixing different meds in the pill crusher if it hasn’t been properly cleaned in between patients (Uh oh). Another way it may impact the dose is by changing its bioavailability (the volume of the chemical) which may increase or decrease depending on the medication itself and the consistency its provided with.

Crushing meds could also mean that the med may break down in the throat or the esophagus instead of the stomach where the mucosa is less protected against harsh chemicals. If you didn’t know this, you’re not alone. Crushing medication also means you are not getting it all at once in one compact little package. Once you crush the medication and put it in a puree, you run the risk of some of it hanging behind in the oropharynx which at best means the patient isn’t getting their full dose and at worst could mean the medication may have a caustic effect on the sensitive oropharyngeal mucosal lining.

Lastly, crushing medication and providing it with a consistency other than water may be considered “off-label” distribution which is illegal as the pharmaceutical company probably hasn’t tested that particular form of distribution.

More details and research on the adverse effects of pill crushing can be found on this article from Dysphagia Cafe. And here is some research identifying the medications that we need to avoid crushing.

The solution

Not all pills are created equal. There are large small, coated, non-coated, round, oval, and of course liquid, and solid. So what’s easier to swallow? What’s harder to swallow? Thankfully we have some research here and here to help us out with this one. Patient’s generally prefer medications that are…

• Small (no surprise there)

• Coated

• Capsules

• Strongly arched in contour

• Oval shape for larger pills

• Rounder shape for smaller pills

• White (no explanation offered with this one!)

Some other basic strategies to improve oropharyngoesophageal (say that word 3x fast) transit is with an upright position and lots of water (50 mL to be exact). This level of thin liquid consumption of course isn’t recommended for patients with dysphagia, but might be a good option for those with an otherwise healthy swallow.

None of these strategies are helpful or possible? If bolus propulsion and pharyngeal sticking is the issue, there is some research indicating that a lubricating spray such as pill glide may help move things along a bit. A pill swallowing gel such as Gloup may also be an option for your patient, which comes with thickened options and also can also shield the taste of the medicine. Keep in mind, these devices may be contraindicated for some patients with dysphagia. Which makes sense, right? If someone has a delayed swallow, you don’t necessarily want to be lubing up their pill and shooting it down their pipe.

Takeaways

Pills aren’t fun. Your patient may agree. Speak with the pharmacist to see if the medication can be administered in a form that is easier to swallow as noted above. If I haven’t scared you out of recommended crushing meds COMPLETELY, consider asking the pharmacist about which medications can be crushed and provided in applesauce or another consistency. NPO except for medication is rarely a good idea. If they can’t swallow food and liquid, chances are they can’t swallow medication either. More on that issue here. Finally, consider lubing up those pills for your patient with intact cognition and without a significantly delayed swallow or a high risk for choking.

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