Swallowing difficulties and tablet crushing

Swallowing difficulties

Some residents have difficulty taking medicines orally. You must monitor how the residents are responding to taking medicines to ensure that the resident’s needs are adequately met.

You should look out for the signs of difficulty such as:

• Coughing or choking soon after swallowing
• Food, fluid and medication remaining in the mouth after swallowing
• Food and drink spilling from the mouth
• Wet gurgled voice after taking a drink
• Excessive oral secretions
• Residents complaining of the sensation of food or fluid being stuck in the throat

It is important to ensure that posture and positioning are maximised during feeding. If residents require close supervision and assistance this should be provided.

If there is a new onset of dysphagia (swallowing difficulty) or a deteriorating swallow, then refer to local guidelines to make a referral to the speech and language therapist. If you identify that a resident is having difficulty swallowing, this should be reported to your line manager.

If problems are severe then an urgent medical referral should be made. If the cause of swallowing difficulties is medication related, then discuss this with the GP or pharmacist for a review of medication to be conducted. The prescriber may try alternate routes e.g. Patch, orodispersible tablet or liquid formulation. Where there isn’t an alternate formulation, the prescriber may consider tablet crushing.

Crushing tablets

If a patient comes into harm from taking medicines, the manufacturer is liable for this.

If tablets are altered or crushed, this means that it is being used in an unlicensed way and it will lose protection of the Consumer Protection Act 1987. The manufacturer will not be liable for harm caused by the altered medication but the prescriber who instructed the medicine to be administered in an unlicensed way becomes accountable.

Carers are NOT allowed to crush tablets or open capsules without the permission of an appropriate prescriber. In some special circumstance, tablets may need to be crushed before administration. This should be outlined in the resident’s care plan.

If the medication to be administered to a patient has been prescribed with directions to crush tablets, then the following guidance should be adhered to:

• Tablets should be crushed using a tablet crusher and cleaned between residents or ideally each resident should have their own tablet crusher
• Tablets should be crushed and administered one tablet at a time
• Every effort should be made by the carer to minimise exposure to dust particles
• Only crush those medicines that are necessary to crush. Residents may be able to take some tablets with water and not others.

Help and advice on swallowing difficulties and information on different types of tablets, coatings and formulations can be found on the swallowing difficulties website

Watch the video which outlines good and bad practice in tablet crushing for medicines administration.

Covert administration of medicines

You should only administer medicines in line with national and covert medication policy and the guidance of the Court of Protection.

Care home staff must ensure that covert administration only be used:

• As a last resort when all other methods have been tried
• When the resident lacks capacity to make decisions
• When there has been a formal ‘best interests meeting’ approving this
• When the resident’s doctor confirms this as a medical necessity
• If the best interests assessor has reviewed the decision and agreed with it

Care home staff must ensure that the best interests meeting:

• Is recorded
• States clearly how the medicines should be administered
• States when and how the decision will be reviewed

Staff must ensure that covert administration is:

• Used for the minimum possible time
• Not deemed to be a breach of Human Rights
• Authorised using the Deprivation of Liberty Safeguards process

This information will come in useful for the final steps which test your understanding. You can come back to, pause or replay the video as you need.