Pill Swallowing - Are we missing something?

Reliance on solid oral medications for so many conditions requires an ability to swallow medication.

Older people often suffer from swallowing disorders, too, which are caused by a decrease in saliva formation in old age so that the solid medicament forms may be swallowed only with difficulty. They react with reluctance to the regular ingestion often necessary over many years which frequently leads to irregular compliance.

Tablets are solid dosage forms in which powders, crystalline or granular form of drug and other inactive excipients like lactose, that are commonly manufactured by compression into a cylindrical disk-like shape. It is the most frequently used means of administering a drug. However, the frequency of solid oral dosage form swallowing problems and its impact on swallowing-related quality of life domains remains a neglected issue in 2019. The growing body of literature showing oropharyngeal dysphagia related eitologies and patient reported swallowing complaints highlight the difficulties in effectively addressing dysphagia-symptoms associated to swallowing solid dosage forms and often leads to or contributes to nonadherence.

In an attempt to solve these problems, numerous alternatives have been offered in the market place. However, tablets for chewing or sucking and orodispersible tablets are not a genuine alternative either, especially for young children. Due to dental problems, older people often have an aversion against chewable tablets, too, and sucking tablets or orodispersible tablets are not convincing either due to reduced salivation.

In cases where special oral preparations must be made, such as converting tablets or powder preparations into a suspension with a certain amount of water almost always require preservation, kept refrigerated and generally entail high production costs. Often mistakes are made when the suspension is prepared. By foaming or insufficient agitation before application, problematic dosing errors may occur, and especially frail older people may have physical administering problems with this dosage form.

With young children or adults with swallowing disorders, a syrup is often chosen as an alternative. In many cases, however, problems occur because the active ingredient is very bitter. Syrups must always be protected by preservatives which have an inherent allergy risk. In many active ingredients, stability problems occur when they are processed into an aqueous syrup.

The prescription and administration of medicines is an essential aspect of patient care, but swallowing difficulties can compromise a person’s ability to take solid medication and around 60% of people over the age of 60 have experienced trouble swallowing pills or capsules at some time. It has also been found 68% of elderly people in institutionalised environments experience moderate to severe dysphagia.

What effect does non-adherence have on health? The answer is substantial worsening of disease, death, and increased health care costs.

Some people can accurately describe their swallowing problems. Others may not recognise that they have a swallowing problem and may take too much food or liquid into the mouth too quickly, causing coughing episodes or choking. Have you ever or known anyone who needed a second attempt to swallow a tablet wherein you or they could not succeed the first time ? It is a rather unpleasant experience. For patients who are bed-bound or receiving care, some carers have even resorted to covert administration, many often employ crushing/physical tampering of tablets and/or capsules and mixing with food for the sake of getting the medicine into the patients system.

Many of us are aware, food or liquid can often go down the wrong way into the airway or lungs; this is called ‘aspiration’. Sometimes food or liquid can go into the airway with no coughing; this is called ‘silent aspiration’. Elderly patients who struggle to swallow foods will often find taking solid oral medication challenging.

Within the area of medication adherence, there are several types of nonadherence. The first is what is commonly called nonfulfillment, in which providers write prescriptions but the medication is never filled (also known as primary nonadherence). In this case, providers have made recommendations about a course of therapy that the patient ultimately does not initiate. This first type of nonadherence includes patients who fill the first prescription for a new medication but never take it.

A second type of nonadherence is called nonpersistence, in which patients decide to stop taking a medication after starting it, without being advised by a health professional to do so. Most patients who stop their medication will do so within the first six months of starting. Nonpersistence can happen, though, at any point in time and is only rarely unintentional (e.g., when patients and providers miscommunicate about therapeutic plans).

A third type of nonadherence we call nonconforming, which encompasses a variety of ways in which medications are not taken as prescribed; this behavior can range from skipping doses, to taking medications at incorrect times or at incorrect doses, to even taking more than prescribed. The types of nonadherence underscore the challenges in achieving full adherence: A medication must be appropriately prescribed, filled, initiated, continued, and taken as intended. 

What causes pill swallowing difficulties?

There are physiological and psychological underlying reasons causing pill swallowing difficulties. Normally, the muscles in your throat and oesophagus squeeze, or contract, to move food and liquids from your mouth to your stomach without problems. Sometimes, though, food, liquids and even medicinals have trouble getting to your stomach and many of these problems begin in the mouth.

There are many different problems that can prevent the mouth, throat or oesophagus from working properly. Some of these are minor, and others are more serious i.e. neck cancer. A loss of muscle mass and function in the throat helps explain why many geriatric and people with neurological disorders have difficulty swallowing. Despite these facts, for many people, anxiety is a major contributor to pill swallowing difficulties; the difficulty in swallowing occurs because of an over-sensitivity to our body. As you know, most bodily functions are automatic. You breathe without having to think about it. Your hand grips things without thinking about each individual finger. And when you swallow, you do so without consciously moving the muscles in your throat. However if you struggle with anxiety, especially during a panic attack, your mind becomes too focused on things that should be automatic, and you become overly aware of this. You can still swallow, but when you do so, it no longer feels like a natural reflex. The good news is that you're unlikely to choke, but your body is so overwhelmed with anxiety that what used to be an automatic response becomes less so. Knowing how to swallow medication in pill form doesn’t come naturally it’s a skill that must be learned.

One key feature absent in swallowing solid oral medication in comparison to solid foods is the absence of masticatory oral processing. For instance, chewing is an extremely important, yet oftentimes overlooked, part of healthy digestion. Most people put food in their mouth, chew a few times, and swallow. The action of chewing mechanically breaks down very large aggregates of food molecules into smaller particles and uses saliva to lubricate foods. This results in swallowing smaller, rather than larger, wetted pieces of food reducing oropharyngeal and oesophageal stress during transit.

Another area of concern is certain concurrent medications can exacerbate xerostomia (dry mouth due to lack of saliva), which can make swallowing solid dosage forms of medication (e.g. capsules and tablets) difficult. Drugs that can cause dry mouth include tricyclic antidepressants, antihistamines, antimuscarinic drugs, antiepileptic drugs, antipsychotics, beta-blockers, and diuretics.

The Question

If you have a hard time swallowing once or twice, you probably do not have a medical problem. But if you have trouble swallowing on a regular basis, foods or medication, do seek professional help. As in the case of taking repeat solid oral medications this is a problem that needs to be addressed by formulators who design our medicinals. This begs the question - are we missing something?

Difficulty in swallowing can affect medicines adherence in any patient at any age and younger patients and children may also find tablets too difficult to swallow well into their teenage years. Reliance on oral medications for so many conditions requires an ability to swallow medication. The size and coating of the tablet or capsule is frequently noted as an important factor in surveys of medication swallowing difficulties, but more detailed investigation is necessary.

The practice of tablet crushing or opening capsules to make the medication easier to swallow has become increasingly documented as potentially hazardous – however this has not resulted in crushing tablets becoming less widespread.

Literature reviews show a complex relationship between factors from providers, health-system (including physician-patient communication), patient beliefs/understanding, regimen complexity (i.e. polypharmacy) and formulation design influence patient medication intake behaviour.

In an effort to focus the discussion around a set of clear barriers with evidence behind them, systematic reviews show that providers of all types and the health-care system in general have important roles to play in addressing the patient barriers beginning with education and optimising dosage design for improved adherence.

For those with chronic swallowing and choking problems, mealtime or medication time can be a source of anxiety and dread, rather than a time of enjoyment or feeling of ease. This was written to highlight a crises that afflicts so many people, particularly the elderly and young, who suffer unnecessarily in silence. Despite the prevalence of the issue of swallowing, it has sadly often gotten so little attention in our day to day lives. Difficulty with swallowing problems in the elderly is not just inconvenient. It can impact the person by affecting their diet, their willingness to eat and discontinue their medication. This is a call for the global community to help raise awareness and to advocate for people in crises who are otherwise often forgotten.

Extending courtesies based upon age such as offering your seat in a crowded bus or lifting a heavy bag is not just a matter of convention or kindness but common sense. We will all become that person: a bit more frail every passing year, a little unsteady, occasionally absent minded, frustratingly blurred of vision. We will inevitably need to rely on considerate fellow passengers or observant bystanders. We hope they will anticipate and help. The future seems far away for youths, but soon enough it will be today’s young ones who are the elders. They may one day have to struggle to their feet to make way for youths bent on claiming their rights.”

Olaokun, medical doctor son of the Nobel laureate, Prof. Role Soyinka.

References/Extracts/Images

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Smithard D.G. and O'neill F., 1994, Oror-pharyngeal dysphagia following acute stroke: evaluation and management, Journal of the Hong Kong Geriatric Society, Vol.5 (1), pp.2-7

Steele C., Caslpo R., Greenwood C., Ens I., Robertson C. and Seidman-Carlson R., 1997, Mealtime difficulties in a home for the aged: not just dysphagia, Dysphagia, Vol. 12, pp.45-50

Strachan I. and Greener M., 2005, Medication-related swallowing difficulties may be more common than we realise, Pharmacy in Practice, Vol.15, pp.411-414

Sonja M. Molfenter, Charles Lenell, Cathy L. Lazarus. Volumetric Changes to the Pharynx in Healthy Aging: Consequence for Pharyngeal Swallow Mechanics and Function. Dysphagia, 2018; DOI: 10.1007/s00455-018-9924-5

https://www.buoyhealth.com/symptoms-a-z/trouble-swallowing/

https://swallowingdifficulties.com/healthcare-professionals/prescribe-patients-dysphagia/

https://www.healthspan.co.uk/advice/a-hard-pill-to-swallow-difficulty-swallowing-tablets