With dysphagia becoming a greater burden as the population ages, David G Smithard and Vruti Patel, Department of Elderly Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, highlight the medicine prescribing and administration considerations which must be acted on accordingly.
The taking of medication has become a way of life for the general population, with 48 per cent of the adult population taking at least one prescribed medicine (1), and with 90 per cent of older people taking at least one. Many more will be self-medicating. Medications can be provided in many different formats; the cheapest and most common being tablets or capsules.
Taking medications requires a person to swallow safely. Dysphagia is under-reported, particularly in the older population, where many people have slowly altered their diet (consistency and volume), or subconsciously changed the way they swallow (smaller bolus, taking fluids).
Dysphagia may be the result of a malignant process, neurological insult (stroke, head injury, tumour), progressive neurological disease (Parkinson’s disease, Motor Neuron Disease or Multiple Sclerosis), as well as rheumatoid arthritis and cardiorespiratory disease.
Following investigations, clinical (speech and language therapist (SALT)) and instrumental (videofluoroscopy, fibreoptic endoscopic evaluation of swallowing or pressure impedance), a management plan will be formulated. (2) The approach taken will depend on the underlying aetiology, with the same overall aim – to provide nutrition safely.
The questions that need to be asked are: will the swallow improve? If yes, how can we improve it? How should nutrition be provided, and who will follow the patient up?
If adequate nutrition can be taken orally, there is no need for enteral feeding. However, there may be a need to alter the consistency of food and viscosity of fluids as indicated in the IDDSI guidelines (adopted in the UK). If not, then enteral feeding is often used, via a nasogastic or naso-jejunal tube or percutaneously via endoscopic placement or radiological placement.
Research is following many avenues, four of which are: a. basic science to understand the mechanism of swallowing; b. epidemiology and assessment; c. rehabilitation and recovery; d. safe delivery of medication. Unfortunately, it is often difficult to obtain funding.
Epidemiology and Assessment
As alluded to, the prevalence of dysphagia and swallowing problems is not fully known, however, it’s accepted as an increasing problem in the ageing population. Many studies use different assessment tools and different definitions of dysphagia. Further work using large databases will help, but this will only provide part of the information. A clear consensus on the definition of dysphagia, what is normal / acceptable in older people, and a minimum data set for studies are required going forward.
Screening for dysphagia is a minefield. Many ‘screens of swallowing’ are assessments. A screen needs to be simple and easy-to-use, with reasonable sensitivity and specificity. One such tool is the 4QT which relies on four simple questions. An even simpler way is to watch someone eating if time allows.
Rehabilitation and Recovery
In head injury and stroke the ability to swallow may recover over time. In conditions where muscle weakness is an issue (frailty, under- nutrition, cardiorespiratory disease) what can be done to improve the swallow and the amount eaten?
A study in Japan noted that frail older adults who underwent dysphagia rehabilitation after admission were more likely to be taking a normal diet and eating more.
At present, many workers are investigating muscle strength exercises of the tongue and the suprahyoid muscles. There are several devices that can be used for tongue training, with evidence suggesting that the swallow will improve.
Suprahyoid muscle exercises, such as shaker manoeuvres, chin tuck against resistance, and laryngeal resistance have shown promising physiological results, mainly in a normal adult population. The AblilexTM device and Iqoro are simple devices that have shown to have some benefits, but further evidence is required.
Medication errors are common when people have swallowing problems. (3) Staff and patients may crush, dissolve, or hide medications in food. These all raise legal and ethical challenges. Medication may get missed or not taken, putting people at risk.
Two things need to take place. Prescribers need to consider whether a particular medication is required, and the route medication is administered. Does an alternative formulation exist, such as a liquid, patch, melt / wafer, or granules that can be used instead? Will the dissolved, crushed, suspended medication interact with a feeding tube? How will thickeners added to liquids or liquid medications affect absorption of medications (4)? Who will do the research in these areas? Responsibility will rely on academic research as commercially the research will be expensive and falls between too many stools.
Secondly, clinical staff need to be educated as to the law on prescribing and manufacturing (crushing and mixing tablets), and alternatives to tablet formulations. Recently the Patient Association undertook some work and have produced a web page and a Charter (5) to educate care staff.
Further work is required to understand the prevalence and impact of dysphagia. More research needs to be undertaken to improve dysphagia identification, assessment, and rehabilitation. The impact of dysphagia management on medicine prescribing and administration needs to be better understood by the multidisciplinary team.
1. Moody A, Mindell J, Faulding F, Neave A. Health Survey for England 2016: Prescribed medicines. NHS Digital. Health and Social Care Information Centre
2. 2. Baijens LWJ, Calve P, Cras P et al. European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interventions in Aging 2016;11:1403-1429
3. Holland J, Desborough J, Goodyer L et al. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and metaanlysis. B J clin Pharm. 2008;65:303-316
4. O’Keefe ST. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatrics 2018;18:167
5. The Patient’s Association. Care Home charter for Swallowing and medicines. 2018. https://www.patients-association.org.uk/blog/care-home-charter-for-swallowing-medicines