Authors: Amie Blaszczyk, Nicole Brandt, Jeremy Ashley, Nancy Tuders, Hannah Doles, Richard G. Stefanacci
Categories: Review Article
Source: Drugs & Aging
Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team—including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers—is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.
Dysphagia, or a disruption in the swallowing process, is common in older adults, occurring in 11–14% of adults ≥ 65 years of age and 36% of residents in the skilled nursing setting [1–3]. Age-related sarcopenia and physiologic changes in oropharyngeal swallowing, comorbidities such as stroke and Parkinson disease, and certain classes of medications are associated with onset of dysphagia [reviewed in reference 4]. Because patients with dysphagia may experience difficulty swallowing medications, they may choose to not take their medication, or they may seek other administration methods. Liquid, orodispersible, effervescent, topical, and rectal formulations that do not require swallowing a tablet or capsule may be preferable for patients with dysphagia; however, alternate formulations for many medications may be unavailable, unacceptable to the patient, or cost prohibitive [5, 6]. Thus, patients with dysphagia or their caregivers often resort to crushing medications and administering them mixed with a soft food or liquid [4, 7]. This often means mixing with an untested vehicle, which may alter the bioavailability of the medication(s), potentially reducing efficacy or posing safety concerns. Additionally, it is common to crush oral medications for administration via a feeding tube [8].
Although medication crushing is common [7], prescribing information may not include details on acceptability of crushing medications or how to administer once crushed, and inappropriate medication crushing can have unintended or adverse effects [4]. For example, some medications such as those with extended-release formulations or enteric coatings cannot be crushed without substantial alterations to their pharmacokinetic properties [9], and patients may refuse to take crushed medications due to taste [4]. In patients with feeding tubes, administering crushed medications may result in tube obstructions [8] or alter drug bioavailability [10, 11], potentially reducing efficacy or compromising patient safety.
The American Society for Parenteral and Enteral Nutrition (ASPEN) [8] and the US Centers for Medicare & Medicaid Services (CMS) [12] provide general guidelines for administering crushed medications. However, crushing can have unique effects on the pharmacokinetics, efficacy, and safety of individual medications, and standardized protocols detailing best practices for crushing are not available for most medications. Furthermore, surveys suggest that there is significant variability in knowledge and use of appropriate crushing practices among practitioners who administer crushed medications [7, 13]. The purpose of this review is to evaluate the current literature regarding the administration of crushed tablets for patients with dysphagia or who are receiving enteral feeding and to provide actionable clinical recommendations on best practices. The best practice recommendations are primarily intended for hospital geriatrics wards and long-term care (LTC) facilities, with particular attention to practice within the US. A separate section is dedicated to addressing dysphagia and medication modification in the primary care and community pharmacy setting. Current literature was compiled through nonsystematic PubMed and internet searches; included articles were published before May 2023.
Dysphagia is commonly encountered when caring for older adults. In hospital geriatric and LTC settings, it is estimated that approximately one in three patients experience dysphagia [1]. Age-related reductions in muscle mass and elasticity, oral moisture, and taste and smell acuity may contribute to decreases in swallowing ability [14]. However, dysphagia is commonly associated with comorbidities and should not automatically be attributed to the normal aging process [reviewed in reference 15].
Stroke, dementia, Parkinson disease, and other neurologic disorders, as well as rheumatic diseases, respiratory compromise, and tumors involving the respiratory and upper digestive tracts, can lead to dysphagia [14]. Dysphagia is particularly common following stroke; a systematic literature review showed that robust instrumental testing identifies dysphagia in 64–78% of patients who were treated in acute and LTC facilities after experiencing a stroke [16]. Similarly, a meta-analysis of studies that objectively measured dysphagia in patients with Parkinson disease estimated that dysphagia prevalence is 82% (95% CI 77–87%) [17]. Furthermore, a systematic review found that swallowing difficulties were present in 13–57% of patients with dementia, with prevalence varying by type of dementia [18].
Taking certain classes of medications—such as anticholinergics, calcium channel blockers, and dopamine antagonists—has been associated with onset of dysphagia (see examples in Table 1). Medications that affect saliva production, smooth muscles of the esophagus, or the lower esophageal sphincter, as well as those that affect brainstem function or cause dystonia or dyskinesia, can impair swallowing and potentially contribute to dysphagia [reviewed in references 4, 19–21]. More research is needed to understand the prevalence of medication-induced dysphagia to develop guidance for diagnosis and treatment. Nonetheless, consideration should be given as to whether substitutions for these medications are available when treating patients with dysphagia.
Early identification and treatment of dysphagia may help reduce the potential for negative outcomes such as aspiration pneumonia and mortality [15, 22]. If a patient in the hospital or LTC setting presents with overt symptoms of dysphagia, such as coughing after eating or drinking, the nurse, dietician, or other healthcare staff should notify the physician or advanced practice provider, who may then refer the patient for further evaluation by a speech-language pathologist who can develop a plan for managing dysphagia (see recommendations in Section 7, Best Practices) [4]. Importantly, the plan should include recommending food and drink textures that the patient can safely swallow, using the International Dysphagia Diet Standardisation Initiative Framework to categorize food textures [23–25].
The World Gastroenterology Organization guidelines recommend screening for dysphagia within 24 hours after a stroke and in patients with persistent weight loss or recurrent lower respiratory tract infections [15]; dysphagia screening should also be considered in patients with dementia and Parkinson disease. Techniques for identifying dysphagia include basic screening approaches such as questionnaires; clinical evaluations such as water swallowing tests; and instrumental assessments such as video fluoroscopy (the modified barium swallow), endoscopic evaluation, and manometry [15, 26]. Guideline-recommended dysphagia treatment focuses on improving swallowing ability and reducing the likelihood of aspiration into the lungs [15].
Because patients with dysphagia most often have comorbidities requiring pharmacologic treatment, administering treatments despite swallowing difficulties, while minimizing use of medications that may exacerbate dysphagia, is an important aspect of dysphagia management. Additionally, patients with dysphagia may experience a higher risk of medication errors when they cannot easily swallow a prescribed dosage form. An observational study of 65 drug administration rounds in geriatric and stroke units at four acute care hospitals in England found that the frequency of medication administration errors for patients with dysphagia was 46.1% versus 34.8% for patients without dysphagia [5, 27]. Compared with patients without dysphagia, patients with dysphagia were more likely to experience errors related to drug formulation and preparation, as well as errors of omission in which they did not receive a prescribed drug at all. Unintentional errors of omission could be more likely to occur when medications are modified, such as if a nurse leaves a tablet or capsule to disperse and then does not return to administer the medication [28].
Ensuring appropriate medication administration for patients with dysphagia while minimizing errors necessitates an individualized strategy that considers the needs and desires of the specific patient and involves coordination and clinical judgment from the interdisciplinary care team. For example, nursing and front-line care staff can identify patients with difficulty swallowing and notify the prescribing clinician, who can then refer patients with potential dysphagia to speech pathologists for evaluation. Speech pathologists can evaluate patients and develop a plan for managing dysphagia. Finally, pharmacists and prescribers should review the patient’s medication regimen. Review should include considering whether any medications can be deprescribed, for example if the potential benefit no longer justifies the risk of administering to someone with dysphagia or if the medication is a potential contributor to dysphagia. Any decision to deprescribe should appropriately consider the desires of the patient.
When a medication is deemed necessary or is strongly desired by a patient with dysphagia, pharmacists and prescribers should consider whether alternatives are available, including medications with alternative routes of administration. It should also be determined whether remaining medications can be safely altered to facilitate administration, for example by crushing tablets or opening capsules. The plan for medication administration should be developed in consultation with a speech-language pathologist to ensure that medications can be safely swallowed. For example, the speech-language pathologist may determine that a patient may be able swallow tablets but risks aspirating if water is administered with tablets or if the tablet is crushed in water. Additionally, liquid formulations may not be available at a texture that minimizes the risk of aspiration. If a crushed medication is to be administered using a food or liquid vehicle, the speech-language pathologist should be involved to ensure that the texture of the resulting mixture is appropriate and that it can be swallowed while minimizing risk of aspiration. Plans for managing dysphagia must be individualized with input from patients and caregivers, with particular consideration to patients’ treatment goals.
Surveys have shown that crushing tablets is a common practice for delivering medications to patients with dysphagia. A survey of hospital nurses found that 28% of nurses overall, and 67% of nurses in geriatric units, reported crushing medications daily [7]. However, crushing tablets may alter the pharmacokinetics and pharmacodynamics of a drug, potentially increasing the risk of adverse outcomes [29]. Severe and fatal reactions due to inappropriate administration of crushed medications have been reported [30, 31].
Information on crushability in prescribing information is variable, and there exist no centralized resources listing medications that are appropriate to crush. Thus, the interprofessional team must use other resources to evaluate the safety of administering a crushed medication to a patient with dysphagia (Table 2). The List of Oral Dosage Forms That Should Not Be Crushed (commonly referred to as the “Do Not Crush” list) is a resource for identifying medications that are inappropriate to crush. First published in 1982 and periodically updated [32], the “Do Not Crush List” was available from the Institute for Safe Medication Practices (ISMP) until November 2022; it is now available from Thomas Land Publishers [33]. This list includes drug product names, active ingredients, dosage forms, and reasons for the recommendation not to crush [33]. Notably the “Do Not Crush” list also includes information on dosage forms that can only be altered if a specific protocol is followed, for example capsules (such as those containing enteric-coated granules) that may be opened and the contents mixed with food and swallowed without chewing or crushing [33]. In addition, the NEWT guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties [34] and the website https://www.swallowingdifficulties.com have information on crushing safety and potential alternative routes of administration for many medications [35].
Medications may be inappropriate to crush if they have enteric or slow-release coatings; are sublingual or buccal formulations; have the potential to irritate the skin or mouth when crushed; have antineoplastic, cytotoxic, or teratogenic properties; or have a potentially unacceptable taste [33]. Medications that are not designed for oral administration, such as those with coatings and those that are designed for sublingual or buccal absorption, may be inappropriate to crush because crushing would likely affect their absorption and pharmacokinetics [9]. Antineoplastics and other hazardous drugs may be inappropriate to crush because unintentional exposure to powdered drug has a high potential for adverse effects [36]. If it is necessary to crush a hazardous drug, US Pharmacopeia General Chapter 800 contains guidance on safety procedures; guidance includes donning personal protective equipment and crushing in a plastic pouch to contain any dust or particles generated [36].
Despite the availability of information on medication types that should generally not be crushed, real-world studies suggest that potentially inappropriate crushing occurs with alarming frequency. An observational study of 17 geriatric hospital units in Paris, France, found that among 143 geriatric patients with dysphagia, 104 (73%) were prescribed one or more medications that were unsafe to crush based on a national list of safely crushable medications [37]. Out of 110 medications that were prescribed and modified (by crushing tablets or opening capsules), modification was found to be inappropriate in 53 cases (48%), including 14 (13%) with a potential threat of toxicity or overdose and 9 (8%) with potentially reduced or unproven efficacy [37].
Inappropriate medication crushing may occur because processes for determining how and when it is appropriate to administer crushed medications are not in place [7]. For example, in a separate survey of French hospital nurses, 54% of nurses reported that medication crushing is never specified in a written prescription, and 25% reported that the rationale for crushing tablets is never written in the patient record [7]. Similarly, 71% of nurses never consulted a pharmacist if they were unsure about the ability to crush a medicine, and nearly one-third did not know if the care units they worked in had a procedure concerning crushing medications [7].
The results of surveys on medication crushing practices [7, 37] suggest that the risk of inappropriate medication crushing may be reduced by implementing straightforward processes to ensure that medication administration protocols are appropriately reviewed and agreed upon by the entire care team (see recommendations in Section 7, Best Practices). Mode of administration for prescribed medications should be documented in the patient record. When medication crushing is first ordered, a pharmacist should review a patient’s medication list to determine whether any medications are appropriate for crushing, and this review should be documented. Reasons for crushing medications should also be documented, ideally with consultation of both the prescriber and pharmacist. Documentation should also include steps that have been taken to ensure the safety of the patients, such as attempting to identify safer alternatives in consultation with the pharmacist and prescriber, as well as performing a literature search and reaching out to the drug manufacturer for studies that may help determine whether a medication can be safely crushed. Hospital and LTC units should specify resources to be used for identifying medications that cannot be crushed; if clinical judgment requires a potentially inappropriate medication to be crushed, this should also be documented in the patient record. Hospital and LTC units should also consider developing lists of available alternatives to common medications that cannot be crushed to aid prescribers in ordering appropriate medications. Individuals who administer medications should be trained to recognize common features of medications that should not be crushed (such as extended-release formulations or enteric coatings) and to confirm with a pharmacist if there is any question about the suitability of modifying a medication.
Once the care team has decided to deliver a crushed oral medication to a patient, the method of medication delivery should be carefully considered. The method by which a tablet is crushed can affect its pharmacologic properties, and medication loss during crushing can change the dose the patient ultimately receives [9, 38]. Choosing a vehicle (eg, water, applesauce, pudding) to deliver a crushed medication can affect its biochemistry and absorption [39]. The care team must also decide how to administer multiple medications, while maintaining compliance with governmental or local regulatory guidance [12, 40]. Variation in each aspect of delivering a crushed medication has the potential to affect medication efficacy and patient safety. Thus, an individualized review of medication crushing should be conducted for each medication in consultation with a pharmacist; hospitals and LTC facilities should avoid blanket orders specifying that medications may be crushed. Procedures for administering crushed medications should also be discussed thoroughly with the patient and caregivers, with particular care to avoid medication crushing being misconstrued as covert administration.
A variety of manual tablet crushers are commonly used in hospital and LTC settings; using one of these devices typically involves moving a lever up and down to crush a tablet on a pad or making a rotating motion to grind a tablet within a container. Because medication crushing is most often performed at the bedside [41], commercially available devices crush medications in a disposable cup or bag, or the device is rinsed between uses to avoid mixing medications for different patients [38]. Medication is lost after crushing due to powder being left behind in the bag or cup [38]. A real-world observational study in French hospital geriatric units found that underdosage due to loss of powder occurred in 70% of cases where a mortar and pestle was used [37].
An assessment of medication loss among 24 commercially available medication crushing devices found that medication loss without rinsing ranged from 1.9 to 13.3% depending on the crushing device, with all but six devices resulting in significant drug loss [38]. Use of a ball and socket tablet pulverizer was found to result in the least drug loss, whereas crushing in disposable bags using the Silent Knight Crusher (Medline Industries, Northfield, IL) produced the most [38]. Drug loss ranged from 2.7−9.0% among devices with disposable cups, 2.1–13.3% among devices with disposable bags, and 1.9–7.7% among devices with no disposable vessel, indicating that subtle differences between devices may have more impact on drug loss than crusher type [38]. Among the 12 devices that could be rinsed with water, two rinses reduced drug loss to 0.5–10.4%, whereas performing only a single rinse resulted in drug loss of up to 42.5% [38]. For comparison, US Food and Drug Administration (FDA) guidance for industry on tablets with scoring features requires that manufacturers demonstrate a loss during splitting of < 3.0% of tablet mass to maintain the established pharmacologic properties of the medication [42].
The size of the particles produced when a medication is crushed may also affect its bioavailability [43]. A recent study compared particles produced by crushing melatonin tablets using four different commercially available crushing devices, mortar and pestle, and a tablespoon [44]. Particle size was affected by the type of crusher, with mortar and pestle producing the smallest particle size [44].
To ensure that crushed medications are administered appropriately, and in compliance with governmental or local regulatory guidelines [12, 40], hospitals and LTC facilities should establish clear and consistent protocols for administering crushed medications, including procedures for minimizing medication loss, and ensure that individuals administering crushed medications receive basic training from a pharmacist on how to appropriately crush medications (see recommendations in Section 7, Best Practices). A pharmacist should be available to answer questions related to crushing methods and should review medication orders to ensure that crushed medications are not inappropriately combined. Routine clinical monitoring should be used to ensure that protocols for administering crushed medications are being followed. For example, healthcare providers should monitor changes in disease control or the presence of new adverse events if medication crushing is started or stopped.
Crushing medications eliminates the barrier between the contents of a tablet and patient taste perception; many crushed medications may be unpalatable to patients. Thus, crushed medications are often administered using a liquid such as water or juice or a soft food such as applesauce, yogurt, or pudding to mask product taste. Notably, a study assessing palatability of crushed over-the-counter medications administered to healthy pharmacists showed that some crushed medications were rated as not palatable even when mixed with applesauce [45]. The proportion of pharmacists who would consider palatability in crushing recommendations rose from 47% before the study to 79% after the study. The authors recommended that palatability and patient preferences should be considered when choosing to crush a medication and when selecting a vehicle [45].
Choice of vehicle can alter drug pharmacokinetics and absorption, potentially affecting product efficacy, and volume of vehicle being administered may affect whether patients receive the full dose if they do not consume the entire vehicle. FDA guidance for industry on selecting suitable liquid or soft-food delivery vehicles for drug administration suggests that vehicles should have minimal fluctuations in their composition or characteristics, including sugar content, acidity, and viscosity [46]. The guidance also recommends consideration of vehicle pH and drug dissolution; other potential changes to drug integrity, potency, or stability; the ability of the vehicle and drug to be supplied as a homogenous mixture; and palatability for patients [46]. However, many medications that must be crushed for patients with dysphagia do not have information on suitable vehicles in the product information.
A limited number of clinical trials have assessed the bioavailability of crushed tablets in various vehicles. A randomized crossover trial comparing the bioavailability and pharmacokinetics of apixaban 10 mg (biopharmaceutics classification system [BCS] class III) whole tablets, crushed tablets suspended in water, and crushed tablets mixed with 30 g applesauce in healthy participants found that the bioavailability of crushed tablets suspended in water or mixed with applesauce was 103 and 83%, respectively, of whole tablet bioavailability [47]. Furthermore, the maximum plasma concentration (Cmax) and area under the concentration–time curve (AUC) of apixaban crushed tablets mixed with applesauce were 21 and 16% lower, respectively, relative to the values observed with whole tablets, potentially due to the viscosity of applesauce delaying dissolution of drug until it passed its preferential absorption site in the upper gastrointestinal (GI) tract [47]. Similarly, a randomized crossover trial comparing the pharmacokinetics of vibegron 75 mg (BCS class III) whole tablets with crushed tablets mixed with 1 tablespoon of applesauce found that Cmax and AUC of vibegron in applesauce were 30 and 10% lower, respectively, relative to the values observed with whole tablets, although this change was not considered clinically significant [48, 49]. In contrast, a randomized crossover trial comparing the pharmacokinetics of ticagrelor tablets with crushed tablets suspended in water found that crushing increased plasma concentrations, while maintaining similar Cmax and AUC upon full absorption [50].
Information on drug biochemistry may also be used to help predict drug dissolution rates and potentially to help identify suitable delivery vehicles. The FDA BCS categorizes drugs into four classes based on their solubility and intestinal permeability [51]. Drug dissolution in vivo is highly dependent on GI tract pH, drug pKa, and viscosity of the vehicle [52, 53]. Several studies have evaluated the interaction among BCS drug class, choice of vehicle, and dissolution of crushed medications using in vitro biochemistry, with results suggesting that the effect of vehicle on pharmacokinetics is likely to be highly drug specific [39, 54–56].
Commercially available thickening agents, commonly used to reduce the risk of aspiration when patients with dysphagia consume liquids, may also affect drug properties. For example, an in vitro study found that mixing crushed amlodipine, atenolol, carbamazepine, or warfarin with water that had been thickened by Easythick powder caused a delay in dissolution [39]. Thickeners have also been reported to inhibit intestinal medication absorption [57] and alter pharmacodynamics [58].
When data from clinical trials are not available or if guidance is not provided in a product label, selection of an appropriate delivery vehicle should be performed in consultation with a pharmacist, accounting for a drug’s biochemical properties and any other information available in the literature. There remains an unmet need for comprehensive resources to identify appropriate vehicle parings for commonly crushed medications. Choice of vehicle and serving size should be person-centered, accounting for palatability and ensuring that the patient can consume a full dose of each medication.
Patients with dysphagia are likely to experience polypharmacy. A recent survey of older adults treated for dysphagia in an LTC or at-home nursing setting showed that patients took an average of 6.3 medications [59]. Polypharmacy may lead to a desire to administer multiple crushed medications simultaneously. A real-world observational study in hospital geriatric units found that when medications were crushed for patients, multiple medications were crushed together in 86% of cases [37]. However, combining multiple crushed medications may create unpredictable chemical and physical interactions [8], potentially changing the pharmacokinetics and pharmacodynamics of each drug. These changes can potentially lead to adverse reactions; at least one fatal adverse reaction has been reported following crushing and coadministration of controlled-release labetalol and nifedipine tablets [30]. Guidance from CMS for surveyors of LTC facilities advises that best practice would be to separately crush each medication and administer it mixed with food [12]. The guidance acknowledges that this might not be practical for every resident and recommends an individualized approach considering each residents safety, needs, medication schedule, preferences, and functional ability [12]. This individualized approach should also include input from a pharmacist on the best choice of vehicle and crushing methodology for a patient’s medications. It may also be impractical or time inefficient for staff to crush tablets one at a time; these issues should be reported to the pharmacist and can be a driver to review a patient’s medications and identify potential alternatives. Combining crushed medications is generally not considered a medication error unless there are instructions not to crush the medications [12].
In patients who are unable to consume adequate nutrition by mouth, or who cannot safely consume food and fluids orally due to risk of aspiration, an enteral access device (feeding tube) may be used to deliver food, fluids, and medication directly into the GI tract [4, 8]. A Medicare claims analysis including LTC facility residents ≥ 66 years old with advanced dementia followed from 2000 to 2002 found that the annual overall national incidence of feeding tube insertion was 53.6 per 1000 residents [60]. In patients receiving enteral nutrition, oral medications may be crushed and delivered through the feeding tube [8]. Enteral medication delivery is associated with unique challenges including tube obstruction and the potential for reduced drug absorption and efficacy, along with risks of increases in adverse events [8].
Although enteral medication administration may not be covered by prescribing information, resources to support enteral administration are available. The ASPEN enteral nutritional practice recommendations provide a list of best practices and techniques for healthcare professionals to leverage for enteral medication administration (https://www.nutritioncare.org/clinicalguidelines) [8]. The Handbook of Drug Administration via Enteral Feeding Tubes is also a valuable resource with specific recommendations for enteral administration of more than 400 individual drugs, although it exclusively focuses on formulations available in the UK [11]. Don’t Rush to Crush, published by the Society of Hospital Pharmacists of Australia, also provides guidance on crushing and enteral administration of individual drugs, albeit focusing on formulations available in Australia [61].
In the US, enteral medication administration is governed by guidance from CMS, which specifies that surveyors should further investigate if medications are safe to crush despite a “do not crush” instruction in the prescribing information. CMS guidance also suggests that the “do not crush” list can be used to identify medications that must not be crushed [12]. LTC facilities are also required to have up-to-date medication handbooks, which may be used by CMS surveyors. CMS guidance further states that crushing medications despite manufacturer instructions may be acceptable if the clinical record documents why crushing would not adversely affect the resident, or if the facility can provide evidence from the manufacturer or a peer-reviewed publication that crushing will not compromise care; however, staff are cautioned to watch for pertinent adverse effects [12].
Location of the feeding tube in the GI tract affects drug absorption and must be considered when determining optimal dosing for enteral medication administration [10, 11]. Absorption of most oral medications occurs in the small intestine. However, in some cases the stomach is the target site for drug action, or passage through the more acidic environment of the stomach is required for optimal absorption; these medications will have limited efficacy if the feeding tube empties directly into the jejunum [10, 62]. Conversely, medications with extensive first-pass hepatic metabolism may display increased absorption and greater systemic effects when administered directly into the jejunum [10, 63].
Tube occlusion (clogging) can occur when crushed medications are administered via the feeding tube [8, 11]. Crushing tablets with film or enteric coatings may increase the chances of feeding tube occlusion, in addition to altering the pharmacokinetics of the drug because the coatings do not crush well and tend to aggregate when diluted in water [8, 64]. Therapeutic equivalents and altered dosage forms should be strongly considered for patients receiving medication via their feeding tube [8]. Tablets should be crushed to a fine powder before enteral administration because the smaller particle size improves suspension of the tablet in the vehicle and reduces the likelihood of obstructing the feeding tube [8].
Medications should be administered at least 30 minutes before or after an enteral feeding to prevent issues such as physical incompatibility, decreased drug absorption, and microbial contamination that may occur if medication is delivered during feeding [10, 63]. Ideally, medication should be delivered as a bolus, and feeding tubes should be flushed with 15–30 mL of water both before and after administration [10]. In addition, guidance from CMS for surveyors of LTC facilities states that enteral administration of phenytoin must be separated from nutrition, and failure to do so is considered a medication error among CMS surveyors [12]. Although less common, some medications have specifications on how to administer crushed tablets through enteral feeding tubes, including volumes of liquid to use for flushing, in the full prescribing information; these medications should be administered as the label directs. For example, for rivaroxaban 15- and 20-mg tablets, the crushed tablet suspended in 50 mL water can be administered through a nasogastric or gastric feeding tube and should be immediately followed by enteral feeding [65].
If multiple medications must be administered enterally, they should be administered separately, ideally after flushing the feeding tube with 5–10 mL of water, due to the unpredictable stability and compatibility of crushed drug mixtures and the potential for serious drug–drug interactions [8, 10, 64]. However, flushing the feeding tube after delivery of each medication may be impractical for patients with restricted fluid intake receiving numerous medications. Furthermore, flushing the tube after each medication may be particularly challenging in light of the time it takes to administer crushed medication through a feeding tube. Guidance documents from CMS state that the crushed medications should not be combined and given all at once via feeding tube but notes that a tube does not need to be flushed between each medication if a physician’s order specifies a different schedule due to a fluid restriction [12, 40]. CMS guidance also specifies that the quality assessment and assurance committee, medical director, and pharmacist are responsible for oversight of safe medication practices within LTC facilities [40].
Difficulties swallowing medications are also common in community-dwelling adults. A community-based study found that 19.5% of US adults reported experiencing dysphagia in the previous year, and 3% reported weekly dysphagia [66]. In a separate community-based survey of US adults ≥ 65 years of age, 32.5% indicated that they currently had choking, throat clearing during or after meal time, or difficulty moving food from mouth to stomach [2].
Importantly, people who have trouble swallowing drug tablets or capsules may not self-identify as having dysphagia. A survey of adults in a German general-practice population found that 37% had experienced problems swallowing solid medications [67]. Although significant risk factors for difficulty swallowing medications included dysphagia; stomatitis; diseases of the esophagus; dry mouth; and experiencing choking, coughing, or a globus sensation while eating, few respondents (3%) thought their difficulty taking medications was related to problems they also had with food [67]. Respondents often attributed their swallowing difficulties to medication-related factors such as pill size (75% of respondents), surface (71%), shape (44%), and flavor (22%).
Concerningly, community-dwelling adults or their caregivers may routinely modify medications to facilitate swallowing, potentially without discussing it with their prescriber or pharmacist. In the survey of a German general-practice population, 59% of respondents with difficulty swallowing medications reported modifying their medications to facilitate swallowing; modifications included crushing tablets, opening capsules, and mixing with food or liquids [67]. A separate survey of community-dwelling older adults (≥ 65 years of age) in France who took one or more oral medication found that 17.5% reported modifying their medications; dysphagia was associated with a significantly increased likelihood of modifying medications (odds ratio 4.78; 95% CI 2.39–9.54) [68]. Patients and caregivers who alter medications at home may be at increased risk of crushing inappropriate medications, and patients may experience altered efficacy due to drug loss or variations in how medications are crushed. For example, crushing with a tablespoon can result in much larger particle sizes than crushing with a commercial crusher or mortar and pestle [44], potentially affecting pharmacokinetics and pharmacodynamics.
Given the high prevalence of difficulties with swallowing medications, prescribers should consider routinely asking community-dwelling patients or caregivers if they have difficulty taking their medications or if they have ever modified their medications. The Eating Assessment Tool (EAT-10) is a 10-item survey instrument that may be useful to quickly assess whether patients may be experiencing self-perceived symptoms of dysphagia; it has been translated into several languages by the Nestle Nutrition Institute and is freely available at https://www.nestlenutrition-institute.org/resources/nutrition-tools/details/swallowing-assessment-tool [69, 70]. Although EAT-10 has been used to assess dysphagia prevalence in community dwelling older adults [71], it may not reliably distinguish between different levels of dysphagia severity in the community setting [72], indicating that caution should be used in interpreting EAT-10 results. Prescribers should consider referring patients who report dysphagia symptoms to a speech-language pathologist to be evaluated.
When patients or caregivers report difficulty taking medications at the pharmacy, pharmacists can educate on any medications that must not be crushed, appropriate crushing methodology (including use of a pill crusher), and use of food vehicles or over-the-counter thickeners. Pharmacists should also notify the prescriber and initiate a medication review. The medication review should consider alternative commercially available formulations, substituting uncrushable medications for crushable medications, whether medications are necessary, and pharmacist-compounded formulations. Prescribers should routinely follow up with patients to ensure that they are able to take their medications, ascertain whether any modifications to the medication plan are needed, and consider referring patients to a speech-language pathologist to be evaluated for dysphagia. Recommendations should be individualized and centered on the needs and desires of individual patients and caregivers.
Ensuring the highest standard of care for patients with dysphagia or who receive enteral feeding requires clear communication and coordinated action from the full care team, including physicians, advanced practice providers, nurses, and pharmacists. Practices must be individualized and centered on the needs and preferences of patients and caregivers. We recommend the following best practices, delineated by care setting for each member of the care team.
Dysphagia is common in the general population, becomes increasingly prevalent with age, and often affects patient care in hospital geriatric units and LTC settings. Crushing tablets for administration to patients with dysphagia is a common practice in hospitals and LTC facilities; however, guideline-recommended best practices are not always followed. Appropriate medication formulations, crushing techniques, and, if necessary, feeding tube placements are essential to preserve efficacy and prevent serious adverse outcomes. Owing to the lack of comprehensive evidence and guidance on appropriate crushing techniques and vehicles for specific medications, clinical judgment of healthcare providers is needed to develop an individualized medication administration strategy that is optimal, compliant with governmental or local regulations, and patient centered.
Medical writing support was provided by Joseph Kruempel, PhD, CMPP, of The Curry Rockefeller Group, LLC (Tarrytown, NY, USA), and was funded by Sumitomo Pharma America, Inc. (formerly Urovant Sciences, Inc.; Marloborough, MA, USA).
Funding for medical writing and editorial support in the preparation of this manuscript was provided by Sumitomo Pharma America, Inc. (formerly Urovant Sciences, Inc.; Marlborough, MA, USA).
AB has consulted for AstraZeneca and serves as a geriatrics content consultant for Wolters Kluwer. NT and HD have nothing to disclose. NB is a consultant for Institute for Healthcare Improvement (Faculty), is section editor for SLACK, Inc., and is an author of the American Geriatrics Society Beers Criteria^®^ for Potentially Inappropriate Medication Use in Older Adults. JA is a consultant pharmacist with Medication Managers and a Clinical Pharmacist, Pharmacy Corporate Development, with Brookshire Grocery Company. RGS is an advisor for Sumitomo Pharma America.
Data sharing is not applicable to this article as no datasets were generated or analyzed.
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The first draft of this manuscript was written by a medical writer under the direction of the authors. All authors participated in the review and interpretation of literature and relevant data, critically revised the work for intellectual content, and read and approved the final version for publication.
Data sharing is not applicable to this article as no datasets were generated or analyzed.