As a nutrition pharmacy specialist, Patients with dysphagia will need your advice on how to take oral medictions safely. These patients have difficulty swallowing, often due to neuromuscular or structural changes in the mouth, pharynx, or esophagus. It's common in conditions such as stroke, Parkinson's disease, dementia and head and neck cancers.
Start by offering a medication review to see if any medications can be deprescribed. Also look for medications that may contribute to dysphagia, such as anticholinergics (oxybutynin, etc) leading to dry mouth or medications that may irritate the esophagus, such as bisphosphonates or NSAIDs. Then consider adjustments to help administer medications safely.
Think of NON-oral options such as rectal, sublingual, topical, etc. For example, you can give vancomycin as rectal enema for Clostridium difficile instead of oral route. Ask whether the patient has seen a speech therapist to guide next steps. A swallowing evaluation can assess degree of dysphagia and whether the patient can swallow pills, thin or thick liquids, etc.
Be aware, tilting the head to the side or other techniques (See Our Note) to ease swallowing pills could be risky in some dysphagia patients. If appropriate, suggest adding intact pills or those that can be crushed, split, or sprinkled to soft foods (applesauce, pudding, etc). But check for food interactions first and whether the medication can be altered. Don't automatically turn to liquid medications, since impaired swallowing may lead to aspiration. In fact, expect some patients to need to mix liquids with an OTC thickener. Clarify that starch-based thickeners (Thick up, Thick-It Original, etc) may have a grainy texture and get thicker with time after mixing. Gum-based thickeners (SimplyThick, etc) don't, but may cost more.
- Recommend a different head position, especially with kids. Have patients try tipping their head FORWARD or turning to the left or right. Explain that tipping the head back can actually make swallowing MORE difficult for patients with swallowing disorders.
- Suggest taking pills with chewed food. Advise "hiding" them in some partially chewed, thick, mushy food, such as a banana.
- Suggest a different swallowing method. Advise patients to try washing pills down with water sucked through a straw, or sucked from a plastic water bottle. Explain that the bottle will "crunch in" if they're doing it correctly.
REFERENCES
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Wirth R, Dziewas R, Beck AM, Clavé P, Hamdy S, Heppner HJ, Langmore S, Leischker AH, Martino R, Pluschinski P, Rösler A, Shaker R, Warnecke T, Sieber CC, Volkert D. Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clin Interv Aging. 2016 Feb 23;11:189-208. Available at: https://www.dovepress.com/oropharyngeal-dysphagia-in-older-persons-ndash-from-pathophysiology-to-peer-reviewed-fulltext-article-CIA
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IDDSI Framework. [online] Available at: https://iddsi.org/Framework