Prevalence of swallowing difficulties and medication modification in customers of community pharmacists

BACKGROUND: People may alter their solid oral medication dosage forms to make it easier to swallow. However, modification of solid medication dosage forms can lead to undesirable effects, and people may alter the dosage forms without informing the health professionals involved in their care. AIM: To estimate the prevalence of swallowing difficulties and medication modification amongst community pharmacy consumers, and to investigate consumer views, attitudes, and interactions with health professionals regarding such issues. METHODS: Consumers were recruited from five community pharmacies in Brisbane, Queensland and invited to participate in a structured interview. RESULTS: A total of 369 consumers participated in the study. Overall, 16.5% of people reported experiencing swallowing difficulties, and 10.6% of all respondents reported modifying medication dosage forms. Almost half (44.2%) of those surveyed did not think there would be issues with modifying medication dosage forms. Some consumers would not seek advice from health professionals if they experienced swallowing problems and/or would not seek advice from health professionals before modifying their medication dosage forms, regardless of their thoughts about any problems associated with this practice. CONCLUSION: Some consumers appeared to be accustomed to modifying medication dosage forms, even when there was no apparent or obvious need. People were also reluctant to seek advice from health professionals regarding swallowing difficulties, or modifying medication dosage forms. Health professionals must be assertive in educating consumers about swallowing problems, and medication dosage form modification

Definition, prevalence and burden of oropharyngeal dysphagia: a serious problem among older adults worldwide and the impact on prognosis and hospital resources

Oropharyngeal dysphagia describes difficulty with eating and drinking. This benign statement does not reflect the personal, social, and economic costs of the condition. Dysphagia has an insidious nature in that it cannot be ‘seen’ like a hemiplegia or a broken limb. It is often a comorbid condition, most notably of stroke, and many other neurodegenerative disorders. Conservative estimates of annual hospital costs associated with dysphagia run to USD 547 million. Length of stay rises by 1.64 days. The true prevalence of dysphagia is difficult to determine as it has been reported as a function of care setting, disease state and country of investigation. However, extrapolating from the literature, prevalence rises with admission to hospital and affects 55% of those in aged care settings. Consequences of dysphagia include malnutrition, dehydration, aspiration pneumonia and potentially death. The mean cost for an aspiration pneumonia episode of care is USD 17,000, rising with the number of comorbid conditions. Whilst financial costs can be objectively counted, the despair, depression, and social isolation are more difficult to quantify. Both sufferers and their families bear the social and psychological burden of dysphagia. There may be a cost-effective role for screening and early identification of dysphagia, particularly in high-risk populations

Delivering crushed tablets using thickened fluids : is drug diffusion into gastric fluids restricted?

Solid medications are often crushed and mixed with food or thickened water to aid drug delivery for those who cannot or prefer not to swallow whole tablets or capsules. Dysphagic patients have the added problem of being unable to safely swallow thin fluids so water thickened with polysaccharides is used to deliver crushed medications and ensure safe swallowing. It is postulated that these polysaccharide systems may restrict drug release by reducing the diffusion of the drug into gastric fluids. METHODS By using a vertical diffusion cell separated with a synthetic membrane, the diffusion of a model drug (atenolol) was studied from a donor system containing the drug dispersed into thickened water with xanthan gum (concentration range from 0.005%-2.2%) into a receptor system containing simulated gastric fluid (SGF) at 37°C. The amount of drug transferred was measured over 8 hours and diffusion coefficients estimated using the Higuchi model approach. RESULTS Atenolol diffusion decreased with increasing xanthan gum concentration up to 1.0%, above which diffusion remained around 300 μ2s-1. The rheological measurements captured the influence of the structure and conformation of the polysaccharide in water on the movement and availability of the drug in SGF. DISCUSSION Dose form administration for dysphagic patients’ needs special attention from general practitioners, pharmacist and patients. Improving drug release of crushed tablets from thickening agents requires a reduction in the diffusion pathway (e.g. by decreasing drop size radius). This approach could make the drug available in SGF in a short time without compromising the mechanical aspects of thickening agents that guarantee safe swallowing

Delivering crushed paracetamol tablets using thickened fluids : does it alter the pharmacokinetics?

Dysphagia, often associated with conditions such as stroke, Parkinson’s disease, multiple sclerosis, and dementia, causes patients to have difficulty with swallowing food and/or liquids. These patients require their fluids to be thickened using gum-based thickening powders in order to facilitate safe swallowing. These thickened fluids are also used as a vehicle for delivery of crushed medicines. Our in vitro measurements suggest that thickened fluids can delay and reduce the dissolution of a number of medications. This study was conducted to assess the impact of the use of thickened fluids on the clinical pharmacokinetics of oral paracetamol. METHODS 20 Healthy volunteers were administered a single oral dose (1g) of paracetamol as either whole tablets, crushed with water, crushed with semi-solid jam, or crushed with thickened fluid according to a randomised, crossover design. Saliva samples were collected periodically over 8 hr and paracetamol concentration analysed by HPLC-UV. Non-compartmental pharmacokinetic analysis was conducted using Winnonlin®. RESULTS The mean peak concentration (Cmax) of paracetamol ranged between 5.62 – 8.00 μg/mL. Comparison between the crushed paracetamol with thickened water (Level 900) and other treatment options (whole, crushed with water, and crushed with jam) showed there was a significant difference in Cmax at 90% CI (p < 0.05). Also, whole tablet had a significant difference in Cmax between crushed with water and crushed with jam. There was no significant difference in AUC irrespective of the treatment. DISCUSSION The use of thickened water resulted in alteration in the absorption kinetics of paracetamol. Given this interaction, co-administration with thickened fluids may have important clinical implications for medications with a narrow therapeutic index

Prevalence of swallowing difficulties and medication modification in community pharmacy customers

Community pharmacies are in the prime position to provide information to patients who have difficulties swallowing medication

Medication Lubricants for Oral Delivery of Drugs: Oral Processing Reduces Thickness, Changes Characteristics, and Improves Dissolution Profile

Swallowing oral solid dosage forms is challenging for those who have medication swallowing difficulties, including patients with dysphagia. One option is to mix the drug (whole or crushed) with a thick vehicle (medication lubricant). Previous in vitro studies consistently suggest that thick vehicles could impact the dissolution of solid dosage forms, potentially influencing their therapeutic effectiveness, but do not account for changes that happen during oral processing and swallowing. This study aims to investigate the potential impact of medication lubricants on drug release and examine the effect of oral processing. In vitro dissolution of whole and crushed paracetamol tablets mixed with five commercially available medication lubricants (two IDDSI level 2, two IDDSI level 3, and one IDDSI level 4) were tested with and without oral processing; a medication lubricant with/without paracetamol was placed in the mouth (five healthy volunteers), prepared for swallowing, but then expectorated and assessed for physical characteristics and drug release. Medication lubricants, both alone and mixed with crushed paracetamol tablets, showed a significant decrease in viscosity after oral processing. Without oral processing, IDDSI level 3 and 4 lubricants significantly delayed the dissolution of paracetamol tablets. After oral processing, particularly with crushed tablets, there was a substantial increase in the dissolution rate. These findings suggest that dissolution testing overestimates the impact of medication lubricants on drug dissolution. Therefore, using in vitro dissolution tests to predict the dissolution rate of medications mixed with thick vehicles is discouraged. It is essential to consider ways to incorporate the effects of the oral environment and oral processing on thick vehicles used for oral medication administration.</p

The prevalence and perceived effectiveness of using a medication-swallowing lubricant in aged care facilities across Australia

Objective: To explore the extent of use and perceived effectiveness of using a medication lubricant that is specifically designed to help people who struggle to swallow their solid medications whole. Method: Health care workers of varying professional levels in aged care facilities (ACFs) across Australia who are involved in medication administration were invited to participate in a structured online survey. Results: Of the 355 health care workers who completed the survey, 48% had used the medication lubricant to aid administration of whole and/or crushed solid oral dosage forms, and of these 89% agreed with the statement that “it is effective method to facilitate medication swallowing in residents.” The main benefits of using the medication lubricant were considered to be easier medication administration to residents (49%), reduction in need for crushing of medications (34%), and better adherence with medications (33%). Conclusions: This study showed that using a medication lubricant for aged care residents may facilitate the process of medication administration for health care workers, which they perceive to improve residents' adherence with medications. Serious complications associated with solid dosage form modification may also be decreased by using a medication lubricant, as the need for modifying medications is reduced. Therapeutic Goods Administration (TGA)-approved medication lubricants could therefore be a valuable tool to aid the medication administration for patients who have difficulties swallowing medications. Future research may consider the clinical efficacy and acceptability of medication lubricants specifically for people with swallowing difficulties.</p

Are Medication Swallowing Lubricants Suitable for Use in Dysphagia? Consistency, Viscosity, Texture, and Application of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

Medication lubricants are thick liquids or gels that are designed to aid swallowing of solid oral dosage forms. Tablets and capsules are placed within a spoonful of the product for swallowing. The aim of this study was to describe and compare commercially available medication lubricants in terms of textural suitability for patients with dysphagia. Twelve medication lubricants were characterised according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Apparent viscosity, yield stress, thickness consistency, and various texture features were compared. Gloup Forte was the only medication lubricant classified as IDDSI level 4 (pureed/extremely thick) at room (24◦ C) temperature. Four other Gloup products were IDDSI level 3 (liquidised/moderately thick) at room temperature but testing at 4◦ C or pouring from the container instead of using the pump dispenser resulted in classification as IDDSI level 4. The IDDSI Flow test would have classified MediSpend and Slo Tablets as IDDSI level 3, but their very low yield stress led to these fluids flowing too quickly through the prongs of a fork and so these were classified as <3. Severo was IDDSI level 2. Heyaxon and the two versions of Magic Jelly tested contained lumps, and Swallow Aid had exceptionally high viscosity, hardness, adhesiveness, and gumminess, classifying them as IDDSI Level 7 (“regular textures”) and therefore as unsuitable for people with dysphagia according to IDDSI. This study provides valuable information to help with the selection of a safe medication lubricant with appropriate thickness level suited to each individual with dysphagia.</p

The effectiveness of components of swallowing assessments for identifying people with swallowing difficulties: A systematic review for quantitative evidence

<b>Introduction</b>\ud \ud Clinical bedside assessments (CBA) are often used first-line for diagnosing swallowing difficulties. CBAs are a variety of tools e.g. questionnaires, checklists, swallow tasks, and portable devices with each containing a series of components that help assess an individual's ability to swallow. However, the effectiveness of the components in these tools have not been synthesised systematically in the literature.\ud \ud ..