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Swallowing difficulties and tablet crushing

read the article and watch the video on what to do if patient cant swallow their medication and what to consider when crushing tablets
What we thought to be useful just to make the point, which is to show you what we saw happening to one patient on a ward. And one of our researchers was watching a person administer their medicines. And what they did, they get all the tablets the person was taking and put them in a pestle and mortar. They then opened the capsules in. And once they’ve done that, they just crushed everything up together with a pestle and mortar, like this. So you ended up with their nice colourful sludge at the bottom of the dish. Once they’ve done that and you can see it’s not that easy. It takes a while to do.
And for someone like myself who spent years learning about how we make tablets, and how we design them, it’s very upsetting to see. A lot of thought has gone into these tablets. A lot of thought’s gone into their design. And seeing someone then just mash that up into a fine pulp and crush it, so upsetting. And I lost a bit there. But then what they did was add some water to it to make it into a nice palatable sludge. And once they’ve done that then, they then feed that to the patient. How would you feel about being given those medicines? And what do you think that tastes like?
And the point I’m making here is very often we prescribe medicine for a patient and we just put normal tablets and capsules down and we don’t think about the person administering it. And I believe the person who was administering the medicine was trying to do the best by the patient. They were told that’s what they had to do. They were told they have to get the medicine into the patient. And therefore, in their mind, the best way to do that was to do this. Crush them up add some water and then feed them to the patient.
And what shocked us was we saw patients actually being sick or looking as if they want to be sick whilst they were taking these medicines. So what we need to do is think that alternative approaches, different ways of giving the medicines. First choice is something like Adacal, very nice, chewable. That may be a simple way around. These are designed to be crushed, to be honest with you, because they’re crushed by the mouth. And what’s nice about them as you can see that they’re fruit-flavoured. So actually they’re palatable. Far better flavoured than what we had in that pestle and mortar. The next thing I want to show you is what’s designed for patients who can’t swallow.
Things like soluble prednisolone and soluble Paracetamol. What we have to watch out for though, particularly with effervescent tablets, is they have a lot of sodium in them. So if our patient has a sodium restricted diet, we have to think carefully before we actually start adding water and giving large amounts of these to our patients. But you will see straight away when I pour one of these tablets in to the water, how it dissolves straight away. It is designed to be administered in that way. So that’s the obvious alternatives to use soluble tablets or use chewable tablets. What we’re very often faced with are tablets and capsules. But there are certain shapes which we know patients prefer.
So any oblong and round, patients probably prefer things that are round. So very often you can say, is there a different shaped tablet we could use which is easier to swallow? One thing I want to say though, is that there are certain template such as Nicorandil, which have nothing on to warn you that they’re not safe to crush. There’s nothing in the name at all. But actually when you look at the blister pack, there’s something going on strange there which tells you these may not be appropriate to crush. What’s happening here is we have a large tablet which you do not give to the patient, his is what’s called a desiccant.
And what I mean by desiccant is something that draws the moisture out of the air. So that there is to just make sure the tablets stay dry. And so you’ll see a little system to each of those tablets which is continually drawing the water out. So although there’s no warning with these, these tablets probably are not the best ones to pop out and put in and crush up and add water to because I’m guessing that may break them down rather quickly. This is again why you need to ask the pharmacists. When you see something like this, you start thinking, why is that and why do we have this extra tablets in there.
The next point I want to make is that modified release tablet. So this is a good example of a tablet that is modified release, designed to be taken once a day. And when you open that up and look at the tablet, you will see there’s nothing that gives away, in this case, the fact that it’s modified release. It’s just a bland white tablet. So the first thing to say is, by looking at a tablet, you may not be able to tell that it’s modified release. It does give it away here on the name. It says XL. If you buy the branded version of this one, which we didn’t bring in, actually you can see different layers in the tablet.
And those different layers might give you some idea that there’s something going on and there’s different ways the drug’s being released in each layer. But in this case, just looking at the tablet, you would not know it was modified release. And it’s only when you read the label, that you can see that. Let’s move on to capsules. I have two capsules here, two different drugs. And by looking at them, can you tell which one’s modified release? And the answer is you can’t. There is nothing that gives away the modified release nature of this one so this one. So this one has special granules in. This one doesn’t.
Again if we look at the names however on the boxes, this one actually says, modified release hard capsules. So again, you can see it’s very often highlighted on the packaging, but it isn’t seen in the cspsule. I have another capsule, however which does make it very clear. If you look at this one, and I’ll pop it out so we can show it a bit more clearly. You will see there are little granules in there. So there’s little granules of different size. And it’s the size of those granules and the encapsulation of those granules, which modifies the way the drug is released from that capsule.
So this is a capsule which you should not open and crush because the minute you do that, the patient gets the full dose. And the full dose of betablocker, released immediately is likely to make them dizzy or at least possibly make them dizzy when they stand up and drop their blood pressure very quickly. Next one I’ll show you is a gastro-resistant capsule. This capsule, again you can’t tell really by looking at the capsule itself, it’s just a white capsule, but again you see on the label the term gastro-resistant. And that itself will give you the clue this is something you shouldn’t be opening up and shouldn’t be crushing.
Another alternative to that one, which is gastro-resistant is the all dispersible version of lansoprazole. What that means is you can disperse it in the mouth with water. So we’re opening up, add water to that in the mouth and that will then break up into small granules. So again. with this one, because it’s all dispersal, that doesn’t mean you can crush it. You can let it disperse in water, but you can’t crush it, because as soon as you crush it, you break up the granules as well and change the way it’s released into the body. And get rid of the enteric coating that’s on there to protect it.
The last thing I wanted to show you was these tablets which have been coated and these tablets, which are sugar coated. This is Meptazinol. And this tablet here, I broke in half, I just put my tongue just to see what it tastes like, and it’s incredibly bitter. So again, this one if you’d crushed that and added that to the sludge, it would have been really unpleasant for the patient to take. Similarly, Ibuprofen has either, in this case sugar coating and that coating there again is to hide the flavor of the drug inside.
So when you’ve got something which has a film coating or sugar coating, you do need to think carefully about what does this mean for the patient and what’s it gonna taste like if I decide to crush it for them. Occasionally, you’ll ring up your local medicine information service, and they’ll disintegrate the tablet. So it’s not something that’s designed to be soluble, but equally it’s not got a special coating on it. What they say you should do is take the tablet, put it in some water and just let it disintegrate. And it might take five minutes, it might take 15 or 20 minutes. But they will give you that advice at the same time.
And they will say to you very often, that’s a safe thing to do. One thing I would say counter that, as our experience was, if you tell people to disintegrate tablets and leave them, they do that, but then they forget to come back to them. And there was numerous occasions where we we’re watching staff on the ward where actually staff would leave the tablets to disintegrate, as directed, but then completely forget because they’ve done another five patients before this patient’s has disintegrated and they’ve forgotten to go back and give their medicines.

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.

This article is from the free online

Medicine Administration for Carers

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