Dysphagia literally means difficulty eating or swallowing.1 Dysphagia can adversely affect a person’s health and wellbeing because affected individuals may be unable to take prescribed medication and have difficulties eating and drinking. This article, the first of two, explores how nurses can identify and address difficulties with medication. The second article will explore how nurses can
address problems relating to nutrition and hydration. The prevalence of dysphagia rises with age and is associated with neurological conditions and certain long term conditions. Around 11% of adults living in their own homes have dysphagia.2 Frail older people, those with neurological problems such as stroke and Parkinson’s disease and those with, chronic obstructive airways disease (COPD) are at greater risk of developing swallowing problems (see figure one).3,4,5,6,7
Why does dysphagia occur? The normal swallow has 4 phases (see table one) and is dependent on an intact motor and nervous system.8 Conditions that affect the motor or nervous system such as dementia, stroke, multiple sclerosis and Parkinson’s disease increase the risks of dysphagia. Age related changes including changes to dentition, saliva production and motor function also increase the risks of dysphagia.9 If dysphagia is
suspected
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This guideline was developed by a multidisciplinary expert panel: Wright D et al with the support of a grant from Rosemont Pharmaceuticals Ltd. See bottom of page for full disclaimer. Algorithm for the medication management of adults with swallowing difficulties Management of patients with evidence of swallowing difficulty- The following algorithm assumes that the patient has been assessed
thoroughly, and non-adherence to medication due to a problem with the administration routine has been ruled out
- Check and scroll down the full list of the prescribing system screen display to identify all formulations that are available. If unsure, check with pharmacist and/or Medicines Information Centre to ascertain whether alternative formulations of the medication in question are available, for example:
- transdermal
- parenteral/injectable
- buccal
- rectal
- intranasal
- sublingual
- If a suitable formulation is not available:
- for patients who are not able to take medicines orally:
- consider prescribing an alternative medicine or discontinuing the treatment
- for patients able to take medicines orally:
- consider prescribing an alternative medication
- if no alternative exists, altering a solid-dose oral formulation may need to be contemplated (see below)
- Changing the formulation of a product may alter its bioavailability, efficacy and/or side-effect profile
- do not assume that the dose of a liquid/dispersible formulation will be the same as the solid oral form of a particular product; check dose equivalence
- when switching from a sustained-release to a standard-release form of a medicine, dose
frequency will need to be adjusted accordingly
- evaluate efficacy and side effects frequently
- Dispersible tablets may not give an even solution so part dosing is potentially inaccurate
- Some medicines are available as non-licensed liquid 'specials' or extemporaneous preparations, which are formulated to meet the requirements of a doctor for specific use by an individual patient:
- dose uniformity or reproducibility may not have been tested for extemporaneous
preparations, or some 'specials'
- to minimize the variability of supply, the product specification should be documented: the formulation, method of preparation, and strength should be noted
- For a comprehensive list of products available in liquid or dispersible form, see www.swallowingdifficulties.com
Continuity of care- To ensure continuity of
care, e.g. for patients moving from secondary to primary care:
- any changes to a dosage formulation should be noted, and this information clearly communicated on to subsequent prescribers and other healthcare professionals
- swapping between liquid formulations, particularly liquid 'specials' (which do not have bioavailability data), should be avoided
Altering a solid-dose oral medication- Altering a
solid-dose formulation should be reserved as last-resort and practised only after appropriate advice has been sought from a pharmacist and/or Medicines Information Centre
- Certain types of drug should never be altered without advice from a pharmacist and/or the manufacturers due to the changes these actions impose on the pharmacokinetics and pharmacodynamics of the drug; these include the following types:
- modified release
- enteric coated
- hormonal, cytotoxic or
steroidal
- film and sugar coated
- The outcome of such pharmacological changes can be accentuated in older people due to age-related differences in pharmacokinetics
- Prescribers should also consider:
- how stable the product is once opened to the environment
- whether the safety of the person preparing or administering the product would be put at risk
- alteration of a solid-dose oral formulation should be considered under Control of Substances
Hazardous to Health (COSHH) regulations since there may be an increased exposure to chemical components
- the person may have a hypersensitivity to the product or its constituents
- whether the dose preparation could be accurately repeated
- the amount and type of diluent and/or thickening agents that would be used
- whether the results would be unpalatable
- Variation in the amount of drug reaching the system due to formulation change may impact
efficacy and the potential for side effects, particularly in drugs with a small therapeutic window including:
- phenytoin
- digoxin
- carbamazepine
- theophylline
- sodium valproate
sponsor—
| This guideline has been developed by MGP Ltd, the publishers of Guidelines, and the Working Party was convened by them. Rosemont Pharmaceuticals Ltd was able to recommend experts for the working party group and comment on the scope and title, with final decisions resting with the Chair. Rosemont Pharmaceuticals Ltd had the opportunity to comment on the technical accuracy of this guideline but the content is independent of and not influenced by Rosemont Pharmaceuticals Ltd.
| working party members—
| David Wright (chair, Senior Lecturer in Pharmacy), Debbie Begent (Adult Speech and Language Therapy Service Manager), Hannah Crawford (Consultant Speech and Language Therapist), Mathias Foundling-Miah (Consultant Pharmacist and Barrister at Law), Richard Griffith (Lecturer in Healthcare Law) & Honor Merriman (GP and CPD tutor)
| further information—
| call MGP Ltd (01442 876100) for further information and a copy of the full guideline First included: Oct 06, updated November 2017.
|
How should medications be given for patients with dysphagia?
One option for patients who struggle to take medications with liquid, but are prescribed medications that cannot be crushed, is to bury the pill in a small amount of pudding or applesauce.
How do you give someone medicine who can't swallow?
Try placing a pill on the back of your tongue, drinking water, tilting your chin down toward your chest and swallowing. You can also try putting the pill on the tip of your tongue, drink water and tilt your head back to swallow.
What is the role of the nurse in caring for a patient with dysphagia?
One of the main responsibilities of the registered nurses is screening dysphagia among stroke patients because they have better chances to contact with patients in clinical location and they must learn the accurate guidance of safe feeding of patients with dysphagia [37].
What should the nurse do to assist a patient who is having difficulty swallowing tablets?
Position the patient in a side-lying or upright position to decrease the risk of aspiration. Offer a glass of water or other oral fluid (that is not contraindicated with the medication) to ease swallowing and improve absorption and dissolution of the medication, taking any fluid restrictions into account.
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