Swallowing difficulties and dysphagia
The term “swallowing difficulties” encompasses a range of problems which can affect a person’s ability to swallow solid medication (tablets and capsules); including dysphagia, xerostomia (dry mouth) and a psychological aversion leading to a patient feeling that they can’t swallow capsules and tablets.1
Many different types of patients experience swallowing difficulties and it can affect any age group. Dysphagia is more common in older people due to a higher prevalence of causative diseases and age-related changes which impact swallowing function. It’s important that doctors are aware of any issues that a patient may be having swallowing their medication to enable them to make clinically appropriate decisions.2
Patients with dysphagia have complex needs and often present a medication management challenge for several reasons:2
- Therapeutic outcomes may be compromised in patients who are unable to remain compliant to their medication regime.
- Tablets and capsules may pose a choking and aspiration risk.
- There is a risk of a solid medication becoming lodged in the patient’s throat or oesophagus, resulting in incorrect drug dispersal and subsequent changes in efficacy and/or tolerability, as well as possible oesophageal damage.
- Altering a solid dose medication in order to make swallowing easier for a patient has both medical and legal implications.
Causes of dysphagia and related swallowing problems
Dysphagia describes any impairment of the swallowing process. Dysphagia is not a disease, but a symptom caused by a structural or neurological dysfunction.3
The ‘normal’ swallow needs the respiratory, oral, pharyngeal, laryngeal and oesophageal structures to function with one another. This is dependent on the motor and sensory nervous system being intact.4 There are three phases in the physiology of a normal swallow. Any of these phases can malfunction to produce swallowing problems, i.e. ‘dysphagia’- these are set out in the table below:3
|Oral||Preparation of food and drink for transit into the pharynx. Once the preparation is complete, a bolus is formed. At the end of the phase, the bolus is propelled backward towards the pharynx by the tongue.||Failure to detect material within the mouth can be caused by a sensory or cognitive disturbance.
Uncontrolled material may spill from the lips or into the pharynx. Altered muscle tone affects the action of the jaw, lips, tongue and soft palate disrupting the retention and preparation of the bolus.
|Pharyngeal||Provides a mechanism to prevent material entering the airway. The main activities are the cessation of breathing and closure of the airway.||Aspiration prior to the swallow - Loss of sensation within the pharynx results in absent or delayed initiation of the pharyngeal phase.
Aspiration during the swallow - Incomplete closure of the vocal folds.
Aspiration after the swallow - Incomplete elevation of the larynx results in the failure to clear all material from the pharynx.
|Oesophageal||Describes the transport of the bolus through the oesophagus, consisting of muscle contractions to transport the bolus.||Loss of muscle contractions
Stricture / obstruction
If you would like further information, Rosemont provide a range of resources for healthcare professionals related to swallowing difficulties and the associated topic of medicine management, all available to view online. If you have any questions– please contact us.
1. http://www.sussexpartnership.nhs.uk/sites/default/files/documents/swallowing_leaflet_-_adults_-_ver_1_-_jul_12.pdf (accessed 17th March 2020) | 2. Wright D, Chapman N, Foundling-Miah M et al. Consensus guideline on the medication management of adults with swallowing difficulties. In: Foord-Kelcey G, editor. Guidelines – summarising clinical guidelines for primary care. 30th ed. Berkhamsted: Medendium Group Publishing Ltd; October 2006. | 3. Wright et al. 2011. Prescribing Medicines for Patients with Dysphagia. A handbook for healthcare professionals. | 4. https://www.rcslt.org/speech-and-language-therapy/clinical-information/dysphagia (accessed 19th March)