All this week we have put dysphagia under the microscope, examining the causes and prevalence of the distressing condition that is often undiagnosed.
In our final instalment David G Smithard MD FRCP, consultant in elderly and stroke medicine, chair of the UK Swallowing Research Group, Hon Reader University of Kent, reveals key questions to ask and how to manage patients with dyspghagia in the pharmacy.
Key questions to ask
- Is the medication necessary?
- Is it making the swallow worse (dry mouth, confusion, reduced alertness)?’
- Could the medication actually be assisting the swallow?
- If the medication is necessary what is the best method of drug delivery? This will depend on where the problem is in the swallowing process and the severity of the dysphagia.
- Drug interactions, available formulations, enteral feed and tube/drug interaction are all important areas. Mechanical factors are also key, what bore is the tube, the smaller the gauge, the greater the risk of blockage.
- For those who are able to take medication orally, are tablets feasible or not?
Slow release medications are a particular problem, and may require assistance by the insertion into a ‘jelly-like’ material to aid the swallow.
For others it may be possible to dissolve some of them in water (eg statins) as long as they are swallowed promptly; a full dose may not be taken, or where further dilution is required this may be too little or too much.
For others, the capsule could be broken and the granules sprinkled on food, or the compound removed by syringe and then provided as a liquid/solution.
Others may come as liquid/syrup formulations. Frequently these contain sugar to make them palatable, which could adversely affect the oral microbiological flora or worsen dentition.
More and more medications are becoming available as wafers/melts or skin applications (eg Parkinson’s disease, analgesia).
Staff have often crushed tablets, which is not without risk.
Enteral feeding is another concern.
Tablets may need to be crushed, formulation changed or a different delivery system used.
The last resort is to change the drug.
The enteral tubes are plastic and medications will stick to the tube, reducing the bioavailability of some medicines.
Enteral delivery of medications may change not only bioavailability but also pharmacokinetics.
Both mechanisms may result in under or over treatment depending on the medication.
As a consequence determining the correct dose of medication can be difficult with so many potential interactions in play.
Concern with non-standard preparations is whether the administered dose is the correct (too much/ too little) dose resulting in potential for over or under dosing.
Managing patients with dysphagia in the pharmacy
1. Advising on suitable routes of drug administration, formulation or alternative preparations.
2. Advising on medication timing and alerting nursing staff to drugs that may have to be given outside routine drug rounds.
3. Monitoring for loss of efficacy or toxicity due to drug interactions with feeds and reduced absorption owing to feeding tube site.
4. Educating nursing staff about administration techniques and contributing to in-service training.
5. Liaising with the multi-disciplinary team to identify patients requiring pharmacist
input; producing local guidelines; auditing of administration techniques.
6. Discharge planning: liaison between hospital and community pharmacies over formulations; educating patient or carer about appropriate administration techniques; providing backup.