Dysphagia

Introduction

Dysphagia is the symptom of difficulty or discomfort during swallowing.

• Oropharyngeal dysphagia - Difficulty initiating swallowing or coordinating the movement of food or liquid from the mouth to the upper esophagus.
• Esophageal dysphagia - Difficulty transporting the food or liquid through the esophagus into the stomach.

The 3 most significant consequences of dysphagia are

• Choking risk
• Aspiration pneumonia
• Malnutrition

Common Causes

Optimally, the assessment of swallowing function is performed by a speech therapist or speech language pathologist.

The most common cause of oropharyngeal dysphagia is neurological, associated with conditions such as stroke or Parkinson disease, and swallowing can also be affected by drugs such as antipsychotics, barbiturates, anticholinergics, diuretics and mucosal anesthetics.

• Dysphagia occurring after stroke is reversible or improvable in a majority of cases; however, dysphagia associated with dementia or Parkinson disease has a poorer prognosis.

Drug-induced esophageal injury such as ulcerations or strictures can also result in esophageal dysphagia.

NOTE: Failure to administer medication with adequate amount of water is a common oversight and can result in caustic injury or esophageal obstruction.

Management Strategies

Most common interventions include

• Exercises to strengthen the muscles of the mouth or throat
• Alter the texture or consistency of the food or liquid
• E.g. finely chopped solids or a puree diet.
• For liquids, a cornstarch-based thickener can be added to achieve a nectar or honey consistency.

NOTE: Adherence to altered diet recommendations is challenging since restricting food and drink creates dissatisfaction and resistance.

Ingest Oral Medications

When the ability of swallow medications is compromised, the choices are

• Crushing oral dosage forms
• Selecting a liquid formulation
• Selecting an alternative route of drug delivery (e.g. orodipsersible, transdermal, intramuscular)

Among oral formulations, crushing tablets or opening capsules may be preferred over liquid because

• Liquid formulations tend to be more costly.
• Products formulated primarily for children will require higher volumes to achieve an adult dose.
• The overall volume of liquid could ultimately be large if multiple doses of multiple medications must be consumed.

Crushed mediations should be mixed with a small amount of jelly or similar substance (e.g. water, juice, applesauce, yogurt or pudding).

• Jelly is most often preferred because it is an appropriate texture and consistency for any individual with dysphagia and the sweetness can help mask the medication taste.
• Combining multiple crushed medications may create unpredictable chemical and physical interactions, potentially changing the pharmacokinetics and pharmacodynamics of each drug. The best practice would be to separetely crush each medication and administer it mixed with food, but it might not be practical.

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 feeding tube may be used. However, administration of medication through an enteral tube requires special precautions, such as

• Potential of tube clogging
• Type of tube and where it is placed
• Osmolarity of liquid formulation
• Timing of medication administration around the infusion of enteral nutrition formulations

Crushing or opening tablets or capsules may be unacceptable for some medications, such as

• Enteric-coated medication
• Possible stomach lining irritation or drugs will be inactivated by stomach acid.
• Extended or controlled-release medication
• Dose dumping may increase risk of adverse effects or even cause death.
• It may also results in lack of clinical efficacy due to under dosing at later times.
• Other considerations, such as teratogenicity of the medication being handled.

In these cases, replacing products with an immediate-release version or other drug delivery routes must be considered.

The International Dysphagia Diet Standardisation Initiative

The International Dysphagia Diet Standardisation Initiative was developed to provide a framework, common terminology and descriptions for the consistency of foods and fluids on a worldwide basis.

Testing Methods

External Links

• Swallowing dysfunction and dysphagia is an unrecognized challenge for oral drug therapy, 2012
  
• Better Medicines for Older Patients: Considerations between Patient Characteristics and Solid Oral Dosage Form Designs to Improve Swallowing Experience, 2021
  
• Fatality from administration of labetalol and crushed extended-release nifedipine, 2003
  
• Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations, 2023
  
• The International Dysphagia Diet Standardisation Initiative
  
• Royal College of Physicians - Supporting people who have eating and drinking difficulties